Essentials of Nursing Leadership and Management, 5th Edition

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Rodriguez, K., & Robertson, D. (1992). Selling your talents with a U.S. Health and Human Services. Retrieved May 13, 2008, from
résumé. American Nurse, 24(10), 27. http://bhpr.hrsa.gov/healthworkforce/nursingshortage/
Shingleton, J. (1994). The job market for ‘94 grads. In College tech_report/default.htm
Placement Council, Inc. (ed.). Planning Job Choices. Waymon, L., & Baber, A. (1999). Surviving career. Balance, 3(2),
Philadelphia: College Placement Council, 19–26. 10–13.
Tyler, L. (1990). Watch out for “red flags”on a job interview. Zedlitz, R. (2003). How to Get a Job in Health Care. N.Y.: Delmar
Hospitals, 64(14), 46. Learning.
Unknown. (2005). The devil is in the resume details. Fairfield
County Business Journal, 44(18), 17.

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Nursing Yesterday and Today





OBJECTIVES OUTLINE
After reading this chapter, the student should be able to: Introduction
■ Compare and contrast historical and current definitions of Nursing Defined
nursing.
Florence Nightingale
■ Discuss the contribution of nursing leaders to the develop-
ment of modern nursing: Florence Nightingale, Lillian Wald, Background
Margaret Sanger, Mary Mahoney, Mildred Montag, and Becoming a Nurse
Virginia Henderson. The Need for Reform
■ Discuss the history of men in nursing. The Crimean War
■ Differentiate the roles of the American Nurses Association, A School for Nurses
National League for Nursing, National Organization for Early Health-Care Reform
Associate Degree Nursing, American Academy of Nursing,
and National Institute for Nursing Research. Nightingale’s Contributions
■ Discuss ways for nurses to project a positive image. Lillian Wald
■ Discuss some of the issues faced by the nursing profession Background
over the past century and today. Turning Point
■ Identify changes that will affect nursing’s future The Visiting Nurses
■ Describe actions every nurse can take to promote the profes- The Henry Street Settlement House
sion and high quality of care.
Other Accomplishments
Margaret Sanger
Background
Labor Reformer
A New Concern for Sanger
Contraception Reform
Mary Eliza Mahoney
Background
Contribution to Nursing
Mildred Montag
Meeting the Need with Associate Degree Nurses
Virginia Henderson
Background
Expanding the Definition of Nursing
Contributions to 20th Century Nursing
Men in Nursing
Professional Organizations
ANA
National League for Nursing
National Organization for Associate Degree Nursing
American Academy of Nursing
National Institute for Nursing Research
Specialty Organizations
Health Care Today
Nursing Today
Health Care in the Future
Nursing in the Future
Conclusion

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Introduction profession itself. Her concepts of nursing care
became the basis of modern theory development in
It is often said that you do not know where you are nursing.
going until you know where you have been. Over Lillian Wald, founder of the Henry Street
30 years ago, Beletz (1974) wrote that most people Settlement, is a role model for contemporary com-
thought of nurses in gender-linked, task-oriented munity health nursing. She developed a model for
terms: “a female who performs unpleasant techni- bringing health care to people.
cal jobs and functions as an assistant to the physi- Margaret Sanger, a political activist like many of
cian” (p. 432). Although the image of nurses and the others, is best known for her courageous fight
nursing has advanced considerably since then,some to make birth control information available to
still think of nurses as helpers who carry out the everyone who needed or wanted it. Her fight to
physician’s orders. make Congress aware of the plight of children in
In its history, the nursing profession has had the labor force is less well known but led to impor-
many great leaders. There are several who not only tant changes in the child labor laws. Sanger may
demonstrate the strengths of nursing’s leaders but have been the first nurse lobbyist.
also reflect some of the most important issues that Mary Eliza Mahoney was the first black gradu-
the profession has faced over the past 150 years. ate nurse in the United States. Her professional
Each of these leaders initiated change within the attitude helped to change the status of black nurs-
social environment of the time, using the strategies es in this country.
of change and conflict resolution discussed earlier Mildred Montag proposed having two levels of
in the text. nursing. She developed an associate degree nursing
program at Adelphi University.
Nursing Defined Virginia Henderson was a 20th century
The changes that have occurred in nursing are Florence Nightingale. She wrote the nursing fun-
reflected in the definitions of nursing that have damentals textbook most commonly used by nurse
developed over time.In 1859,Florence Nightingale educators throughout the country for most of the
defined the goal of nursing as putting the client “in last century.
the best possible condition for nature to act upon Many of their characteristics—intelligence,
him” (Nightingale, 1859, p. 79). In 1966, Virginia courage, and foresight—are the same ones needed
Henderson focused her definition on the unique- in today’s nursing leaders.
ness of nursing:
Florence Nightingale
“The unique function of the nurse is to assist the indi-
vidual, sick or well, in the performance of those activ- Background
ities contributing to health or its recovery (or to
Florence Nightingale, an English noblewoman,
peaceful death) that he would perform unaided if he
was born in the city for which she was named—
had the necessary strength, will or knowledge. And to
Florence, Italy—on May 12, 1820. Her father was
do this in such a way as to help him gain independ-
a well-educated, wealthy man who put considerable
ence as rapidly as possible” (Henderson, 1966, p. 21).
effort into the education of his two daughters
Martha Rogers defined nursing practice as “the (Donahue, 1985). Florence Nightingale learned
process by which this body of knowledge, nursing French, German, and Italian. Mr. Nightingale per-
science, is used for the purpose of assisting human sonally instructed her in mathematics, classical art,
beings to achieve maximum health within the and literature. The family made extended visits to
potential of each person” (Rogers, 1988, p. 100). London every year, which provided opportunities
Rogers emphasized that nursing is concerned with for contact with people in the highest social circles.
all people, only some of whom are ill. These contacts were very valuable to Nightingale in
Florence Nightingale is probably the best later years.
known of the historic leaders and is considered the Despite her family’s ability to shelter her from
founder of modern nursing. Nightingale brought the meaner side of life, Nightingale always had an
about change in the care of soldiers, the keeping of interest in the welfare of those less fortunate than
hospital records, the status of nurses, and even the herself. She was never quite content with herself, as

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she was described as a “sensitive, introspective, and religious orders. However, Catholic organizations
somewhat morbid child” (Schuyler, 1992). She was experienced a decline during the Reformation
driven to improve herself and the world around her. when the government closed churches and monas-
When she expressed an interest in becoming a teries. Hospitals were no longer run for charitable
nurse, her parents objected strenuously. They reasons but as a social necessity. Nursing lost its
wanted her to assume the traditional role of a social standing when the religious orders declined
well-to-do woman of the time: marry, have chil- and became a form of domestic service. Nurses
dren, and take her “rightful” place in society. were no longer recruited from “respectable” classes
but from the lower classes of society, women who
Becoming a Nurse needed to earn their keep. Other women who could
In the fall of 1847, Nightingale left England for a no longer earn a living by gambling or selling
tour of Europe with family friends. In Italy, she themselves also turned to nursing. Many had crim-
entered a convent for a retreat. After this retreat, inal backgrounds. They lacked the spirit of self-
she believed that she had been called by God to sacrifice found in the religious orders. They often
help others and became more determined than ever abused clients and consoled themselves with alco-
to pursue nursing. hol and snuff.
In 1851, Nightingale insisted on going to The duties of a nurse in those days were to take
Kaiserswerth, Germany, to obtain training in nurs- care of the physical needs of clients and to make
ing. Her family gave her permission on the condi- sure they were reasonably clean. The conditions in
tion that no one would know where she was.When which they had to accomplish these tasks were far
she returned from Kaiserswerth, she began to work from ideal. Hospitals were dirty and unventilated.
on her plan to influence health care. They were contaminated and spread diseases
Nightingale soon left for France to work with instead of preventing them. The same bedsheets
several Catholic nursing sisters. While in France, were used for several clients. The nurses dealt
she received an offer from the committee that reg- with people suffering from unrelenting pain, hem-
ulated the Establishment for Gentlewomen orrhage, infections, and gangrene (Kalisch &
During Illness, a nursing home in London for Kalisch, 2004).
governesses who became ill. She was appointed To accomplish the needed reforms, Nightingale
superintendent of the home and soon had it well realized that she had to recruit nurses from higher
organized, although she did have some difficulties strata of society, as had been done in the past, and
with the committee. then educate them well. She concluded that this
Because of her knowledge of hospitals, could be accomplished only by organizing a school
Nightingale was often consulted by social reform- to prepare reliable, qualified nurses.
ers and by physicians who also recognized the need
for this new type of nurse. She was offered a posi- The Crimean War
tion as superintendent of nurses at King’s College A letter written by war correspondent W.H.
Hospital, but her family objected so strongly that Russell comparing the nursing care in the British
she remained at home until she went to Crimea. army unfavorably with that given to the French
army created a tremendous stir in England. There
The Need for Reform was demand for change. In response, the Secretary
Fortunately for Nightingale, it was fashionable to of War, Sir Sidney Herbert, commissioned
become involved in the reform of medical and social Nightingale to go to Crimea (a peninsula in
institutions in the middle of the 19th century. After southeastern Ukraine) to investigate conditions
completing the reorganization of the nursing home, there and make improvements.
she began visiting hospitals and collecting informa- On October 21, 1854, Nightingale left for
tion about nurses’working conditions. She began to Crimea with a group of nurses on the steamer Vectis
realize that, to improve nurses’ working conditions, (Griffith & Griffith, 1965). They found a disaster
she would first have to improve the nurses. when they arrived.The hospital that had been built
Up to this time, the guiding principle of nursing to accommodate 1700 soldiers was filled with more
had been charity. Nursing services in Europe were than 3000 wounded and critically ill men. There
provided primarily by the family or by members of was no plumbing, no sewage disposal facilities.

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Mattresses, walls, and floors were soaked with Nurses opened in 1860. The school was an inde-
human waste. Rats, lice, and maggots thrived in pendent educational institution financed by the
this filthy environment (Kalisch & Kalisch, 2004). Nightingale Fund. Fifteen probationers were
The nurses went to work.They set up a kitchen, admitted to the first class. Their training lasted a
rented a house and converted it into a laundry, and year. Although Nightingale was not an instructor at
hired soldiers’ wives to do the laundry. Money was the school, she was consulted about all of the
difficult to obtain, so Nightingale used the Times details of student selection, instruction, and organ-
relief fund and her own personal funds to purchase ization. The basic principles on which the
medical supplies, food, and equipment. After the Nightingale school was founded are the following:
hospital had been cleaned and organized,she began
1. Nurses should be trained technically in schools
to set up social services for the soldiers.
organized for that purpose.
Nightingale rarely slept. She spent hours giving
2. Nurses should come from homes that are of
nursing care, wrote letters to families, prepared
good moral standing.
requests for more supplies, and reported to London
on the conditions she had found and improved. Her book, Notes on Nursing: What It Is and What
At night, she made rounds accompanied by an It Is Not, established the fundamental principles
11-year-old boy who held her lamp when she sat by of nursing. The following is an example of her
a dying soldier or assisted during emergency sur- writing:
gery. This is how she earned the title “The Lady
On What Nursing Ought To Do
with the Lamp” from the poet Longfellow (1868).
I use the word nursing for want of a better. It has
The physicians and army officers resented the
been limited to signify little more than the admin-
nurses despite their strenuous efforts and enormous
istration of medicines and the application of poul-
accomplishments. They regarded the nurses as
tices. It ought to signify the proper use of air, light,
intruders who interfered with their work and
warmth, cleanliness, quiet and the proper selection
undermined their authority. There was also some
and administration of diet—all at the least expense
conflict between Nightingale and Dr. John Hall,
of vital power to the patient” (Nightingale, 1859).
the chief of the medical staff. At one time, after
Dr. Hall had been awarded the Knight This book was one of the first nursing textbooks
Commander of the Order of the Bath, Nightingale and is still widely quoted. Many nursing theorists
sarcastically referred to him as “Dr. Hall, K.C.B., have used Nightingale’s thoughts as a basis for con-
Knight of the Crimean Burial Grounds.” When structing their view of nursing.
Nightingale contracted Crimean fever, Hall used Nightingale believed that schools of nursing
this as an excuse to send her back to England. must be independent institutions and that women
However, Nightingale thwarted his resistance and who were selected to attend the schools should be
eventually won over the medical staff by creating an from the higher levels of society. Many of
operating room and supplying the instruments Nightingale’s beliefs about nursing education are
with her own resources. Although she returned to still applicable, particularly those involved with the
duty, she never fully recovered from the fever. She progress of students, the use of diaries kept by stu-
returned to England in 1865 a national heroine but dents, and the need for integrating theory into
remained a semi-invalid for the rest of her life. clinical practice (Roberts, 1937).
The Nightingale school served as a model for
A School for Nurses nursing education. Its graduates were sought world-
After her return from Crimea,Nightingale pursued wide. Many of them established schools and
two goals: reform of military health care and estab- became matrons (superintendents) in hospitals in
lishment of an official training school for nurses. other parts of England,the British Commonwealth,
The British public contributed more than and the United States. However, very few schools
$220,000 (a great sum of money at that time) to were able to remain financially independent of the
the Nightingale Fund for the purpose of establish- hospitals and so lost much of their autonomy. This
ing the school. was in contradiction to Nightingale’s philosophy
Although opposed by most of the physicians in that the training schools were educational institu-
Britain, the Nightingale Training School for tions, not part of any service agency.

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Early Health-Care Reform at Miss Crittenden’s English and French Boarding
and Day School for Young Ladies and Little Girls.
Nightingale’s work marked the beginning of mod-
Her relatives were physicians and had a tremen-
ern military nursing. As a result of her documenta-
dous influence on her. They encouraged her to
tion of the conditions in Crimea and the nurses’
choose nursing as a career.
efforts to improve them, reforms were undertaken.
Wald attended the New York Hospital School
Nightingale’s statistics were so accurate and
of Nursing. After graduation, she worked as a nurse
clearly reported that she was elected a member of
in the New York Juvenile Asylum. She felt a need
the British Statistical Society, the first woman to
for more medically oriented knowledge, so she
hold this position. At their conference in 1860, she
entered Women’s Medical College in New York.
presented a paper entitled, “Miss Nightingale’s
Scheme for Uniform Hospital Statistics.” Before
Turning Point
this paper was written, each hospital had used its
During this time, Wald and a colleague,
own names and classification systems for diseases.
Mary Brewster, were asked to go to New York’s
Nightingale’s opinions on improving health care
Lower East Side to give a lecture to immigrant
were solicited constantly. This led to another
mothers on caring for the sick. Wald and Brewster
publication, “Notes on Hospitals.”
were shocked by what they discovered there.
For more than 40 years, Nightingale played an
While showing a group of mothers how to
influential part in most of the important health-
make a bed, a child came up to Wald and asked for
care reforms of her time. At the turn of the 20th
help. The boy took her to a squalid tenement
century, however, her energies had waned, and she
apartment where nine poorly nourished people
spent most of the next 10 years confined to her
were living in two rooms. A woman lay on a bed.
home on South Street in London. She died in her
Although she was seriously ill, it was apparent that
sleep on August 13, 1910.
no one had attended to her needs for several days
Nightingale’s Contributions (Kalisch & Kalisch, 2004). Miss Crittenden’s
Nightingale is believed to have been in error in only School had not prepared Wald for this, but she
two areas. First, she did not believe in or appreciate went right to work. She bathed the woman,
the significance of the germ theory of infection, washed and changed the bedclothes, sent for a
although her insistence on fresh air, physical physician, and cleaned the room.
hygiene,and environmental cleanliness certainly did This incident was a turning point in her life.
a great deal to decrease the transmission of infec- Wald left medical school and began a career as an
tious diseases. Second, she did not support a central advocate and helper of the poor and sick, joined by
registry or testing for nurses similar to what was in Brewster. They soon found that there were thou-
place for physicians. She was convinced that this sands of cases similar to the first in just one small
would undermine the profession and that a letter of neighborhood.
recommendation from the school matron was suffi-
The Visiting Nurses
cient to attest to the skill and character of the nurse.
Florence Nightingale was a woman of vision Wald and Brewster established a settlement house
and determination. Her strong belief in herself and in 1893 in a rented tenement apartment in a poor
her abilities allowed her to pursue and achieve her section of New York’s Lower East Side.To be clos-
goals. She was a political activist and a revolution- er to their clients, they gave up their comfortable
ary in her time. Her accomplishments went beyond living quarters and moved into a smaller, upper-
the scope of nursing and nursing education, affect- floor apartment there.
ing all aspects of health care and social reform. It did not take long for the women to build up a
nursing practice. At first, they had to seek out the
Lillian Wald sick, but within weeks calls came to them by the
hundreds. The people of the neighborhood trusted
Background them and relied on them for help. Gradually, the
Born in Cincinnati, Ohio, in 1867, Lillian Wald two developed a reputation among the physicians
moved to Rochester, New York, where she spent and hospitals in the area, and requests to see clients
most of her childhood. She received her education came from these sources as well.

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Wald and her colleagues brought basic nursing time, the number of children sent home from
care to the people in their home environment. schools dropped from more than 10,000 to 1100.
These nurses were independent practitioners who The New York Board of Health was so impressed
made their own decisions and followed up on their that they hired nurses to continue the original
own assessments of families’ needs. Like nurse’s work. Wald’s nurses treated illnesses,
Nightingale, they were very aware of the effect of explained the modes of transmission, and explained
the environment on the health of their clients and the reasons that some children had to be excluded
worked hard to improve their clients’surroundings. from class and why others did not. The nurses also
Wald was convinced that many illnesses result- followed up on the children at home to prevent
ed from causes outside individual control and that recurrence of illnesses.
treatment needed to be holistic. She said she Wald was also responsible for organizing the
chose the title public health nurse to emphasize the Children’s Bureau, the Nursing Service Division of
value of the nurse whose work was built on an the Metropolitan Life Insurance Company, and the
understanding of the social and economic prob- Town and Country Nursing Service of the
lems that inevitably accompanied the clients’ ills American Red Cross. Her dreams of expanding
(Bueheler-Wilkerson, 1993). public health nursing, obtaining insurance coverage
Because she had the freedom to explore alterna- for home-based preventive care, and developing a
tives for care during numerous births, illnesses, and national health nursing service have not become a
deaths, Wald began to organize an impressive reality. However, in view of today’s health-care con-
group of offerings, ranging from private relief to cerns, she was a visionary who believed that health
services from the medical establishment. She care belongs in the community and that nurses
developed cooperative relationships with various have a vital role to play in community-based care.
organizations, which allowed her access to goods She died in 1940 and is remembered as one of the
and jobs for her clients. News of her successes foremost leaders in public health nursing.
spread. Private physicians sought her help and
referred their clients to her for care. Margaret Sanger

The Henry Street Settlement House Background
Within 2 years, the nurses had outgrown their Margaret Higgins was born in Corning, New York,
original quarters. They needed larger facilities and on September 14, 1879. After recovering from
more nurses. With the help of Jacob Schiff, a tuberculosis, which she contracted while caring for
banker and philanthropist, they moved to a larger her mother, she attended nursing school at the
building at 265 Henry Street. This became known White Plains Hospital School of Nursing. In her
as the Henry Street Settlement House (Mayer, autobiography, she described the school as rigid
1994). Nine graduate nurses moved in soon after. and at times inhuman; perhaps this provides an
By 1909, the Henry Street Settlement House indication of where her future interests would take
had grown into a well-organized social services sys- her (Sanger, 1938). During her affiliation at the
tem with many departments. The staff included Manhattan Eye and Ear Hospital,she met William
37 nurses, 5 of whom were managers. Sanger. They married and moved to a suburb of
New York, where she stayed at home to raise their
Other Accomplishments
three children.
Wald is credited with developing school health nurs-
ing. Health conditions were so bad in the New York Labor Reformer
City schools that 15–20 children per school were sent Sanger was very concerned about the working con-
home every day. These ill children were returned to ditions faced by people living in poverty. Many
school by their parents in the same condition. As a workers were paid barely enough to buy food for
result, illnesses spread from child to child. themselves and their families. At that time, the
Ringworm, scabies, and pediculosis were common. income for a family with two working parents was
To prove her point about the value of communi- about $12–$14 a week. If only the father worked,
ty health nurses, Wald set up an experiment using earnings dropped to $8 a week. When only the
one nurse for a month in one school. During that mother worked, the family income was lower. A

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portion of this income was paid back to the com- Three months later, Sanger was called to the
pany as rent for company housing. Food was often same home. This time, the woman was in a coma
purchased through a company store, and very little and died within minutes of Sanger’s arrival. At that
was left for other expenses, including health care. moment, Sanger dedicated herself to learning
A major strike of industrial workers in about and disseminating information about birth
Lawrence, Massachusetts, marked the beginning of control.
Sanger’s career as an advocate and social reformer.
The workers had previously attempted a strike for Contraception Reform
better conditions, but they conceded because of This task turned out to be far more difficult than
threatening starvation. If the workers went on Sanger had expected. The Comstock Act of 1873
strike, then there was no money for food. Strike classified birth control information as obscene.
sympathizers in New York offered to help the work- Unrewarding research at the Boston Public Library,
ers and to take the children from Lawrence into the Library of Congress, and the New York
their homes. Because of her interest in the situation Academy of Medicine only increased her frustra-
of the underpaid workers and her involvement with tion. Very little information about birth control was
New York laborers, Sanger was asked to assist in the available anywhere in the United States at that time.
evacuation of children from the unsettled and But contraception was widely practiced in many
sometimes violent conditions in Lawrence. European countries, so Sanger went to Europe.
Following an outbreak of serious rioting, she She studied methods of birth control in France,
was called to Washington to testify before the and when she returned to the United States, she
House Committee on Rules about the condition of began to publish a journal called The Woman Rebel.
the children. She testified that the children were This journal carried articles about contraception,
poorly nourished, ill, ragged, and living in condi- family planning, and other matters related to
tions worse than those in impoverished city slums. women’s rights.
Two months later, the owners of the mills sat The first birth control clinic in the United States
down to talk with the workers and gave in to their opened at 46 Amboy Street in Brooklyn, New
demands. Sanger’s interventions on behalf of the York, in 1916. Sanger operated the clinic with her
children had brought the workers’ plight to the sister, Ethel Byrne, and another nurse, Fania
attention of the general public and to people in Mindell. On the first day, more than 150 women
Washington. asked them for help. Everything went smoothly
until a policewoman, masquerading as a client,
A New Concern for Sanger arrested the three women and recorded the names
In the spring of 1912, Sanger returned to work as a of all the clients. To bring attention to their plight
public health nurse. She was assigned to maternity and to the closing of the clinic, Sanger refused to
cases in New York City’s Lower East Side. One ride in the police wagon. Instead, she walked the
case became a turning point in her life. Sanger was mile to the courthouse.
caring for a 28-year-old mother of three children Several weeks later, Sanger returned to a court-
who had attempted to self-abort. This woman and house overflowing with friends and supporters to
her husband were already struggling to feed and face the charges that had been filed against her.The
clothe the children they had and could not afford public found it difficult to believe that this attractive
any more. After 3 weeks, the woman had regained mother, flanked by her two sons, was either
her health. However, during the physician’s final “demented” or “oversexed,” as her adversaries had
visit to her home, he told the young woman that claimed.She did not deny the charges of disseminat-
she had been lucky to survive this time but that, if ing birth control information, but she did challenge
she tried to self-abort again, she would not need his the law that made this information illegal. Because
services but those of a funeral director. The young she refused to abide by that law, the judge sentenced
woman pleaded with him for a way to prevent her to 30 days in a workhouse.
another pregnancy. The doctor replied, “Tell your After completing her 30 days, Sanger continued
husband to sleep on the roof” (Sanger, 1938). The her work for many years.She solicited the support of
young woman then turned to Sanger, who wealthy women and used their help to gain financial
remained silent. backing to continue her fight. She gave talks and

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organized meetings.In 1921 she organized the Birth Contribution to Nursing
Control Conference in New York (Kalisch &
Mahoney recognized the need for nurses to work
Kalisch, 2004). In 1928 she established the National
together to advance the status of black nurses with-
Committee on Federal Legislation for Birth
in the profession. In 1896 Mahoney became one of
Control, which eventually became the Planned
the original members of the predominately white
Parenthood Foundation. Sanger was also an accom-
Nurses Associated Alumnae of the United States
plished author, writing What Every Girl Should
and Canada (later known as the American Nurses
Know, What Every Mother Should Know, and
Association [ANA]). She cofounded the National
Motherhood in Bondage.
Association of Colored Graduate Nurses
Conservative religious and political groups were
(NACGN). Mahoney delivered the welcoming
the most vocal in their opposition to Sanger’s work.
speech at the first convention of the NACGN and
In the end, however, Sanger won. Planned
served as its national chaplain.
Parenthood is a thriving organization, and birth
Mahoney died on January 4, 1926, and was
control information is available to anyone who
buried at the Woodlawn Cemetery in Everett,
seeks it, although some groups oppose its availabil-
Massachusetts. In 1936, the NACGN created an
ity on religious or political grounds.
award in her honor for women who contributed to
Sanger could fairly be labeled an early example
racial integration in nursing. After the NACGN
of the liberated woman. She was independent and
was dissolved in 1951, the ANA continued to offer
assertive during a time when it was considered
this award to black women. In 1976, 50 years after
politically incorrect for a woman to behave that
her death, Mary Eliza Mahoney was inducted into
way. Her tenacity and her ability to bring the needs
the Nursing Hall of Fame.
of the poor to society’s attention represented that
When she entered nurse’s training, Mahoney
part of caring that operates in the political arena to
never envisioned how her simple act of becoming a
bring about change to improve people’s health and
nurse would change the status of black nurses and
save lives.
help them to attain leadership positions within the
profession. Her dedication and effort have been
Mary Eliza Mahoney
an inspiration to many men and women of color
who became dedicated members of the nursing
Background
profession.
Mary Eliza Mahoney was the first African-American
registered nurse (RN) in the United States. She was
born on May 7, 1845, in Dorchester, Massachusetts. Mildred Montag
She grew up in Roxbury with her parents and
showed an interest in nursing during her adoles- Meeting the Need With
cence. She worked for 15 years at the New England Associate Degree Nurses
Hospital for Women and Children (now Dimock During World War II, a nursing shortage became
Community Health Center). She was a cook, a evident.To meet the demands for nurses, Congress
janitor, a washerwoman, and an unofficial nurse’s enacted the Bolton Act of 1943 creating the
assistant. United States Cadet Nurse Corps. Under the
In 1878, at the age of 33, she applied to the Bolton Act, nurses could be educated in fewer than
hospital’s nursing program and was accepted as a 3 years but perform the same nursing duties as their
student. She spent her training days washing, counterparts from the traditional 3-year diploma
ironing, and cleaning, expected competencies of schools (Applegate, 1988). Mildred Montag devel-
that time. Sixteen months later, of the 43 students oped such a program at Adelphi University.
who began the rigorous course, Mary and After the war, federal funds were withdrawn, and
4 white students were the only ones who com- the numbers of graduates declined.The acute nursing
pleted it. After graduation she worked mostly as shortage continued.The time for a change in nursing
a private duty nurse. She ended her nursing education had come. The postwar era created other
career as director of an orphanage in Long Island, job opportunities for women, and hospital-based
New York, a position she had held for a decade. diploma school was not a popular career choice. The
She never married. health-care delivery system was disease-oriented.

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New technologies had entered the field of health care,
requiring nurses to have a stronger background in the Expanding the Definition of Nursing
sciences and be able to use these technologies at the Virginia Henderson’s most important publication,
bedside. Principles and Practice of Nursing, is considered the
In 1952 a project aimed at developing nursing 20th century’s equivalent to Nightingale’s Notes on
education programs in junior and community col- Nursing. Nightingale had emphasized nature as the
leges was launched. Montag, now an assistant pro- primary healer but, with the advent of antibiotic
fessor of nursing at Columbia Teacher’s College,was therapy and other technological advances, this
appointed the project coordinator.Montag proposed approach needed expansion (Henderson, 1955).
two levels of nursing, creating what she described as In her textbook revision in 1955, Henderson
the technical nurse. This nurse would provide direct, first offered her description of nursing: “I say that
safe nursing care under the supervision of the pro- the nurse does for others what they would do for
fessional nurse in an acute care setting (Haase, themselves if they had the strength,the will and the
1990). The curriculum included general education knowledge. But I go on to say that the nurse makes
courses to prepare the nurse for social and personal the patient independent of him or her as soon as
competency as well as skill competency.Today, asso- possible.” Henderson wrote three editions of this
ciate degree programs provide more graduate nurses textbook. Unlike other nursing textbooks, this one
than any other nursing programs. emphasized the importance of nursing research.
Associate degree nursing education has had a Nurse educators continued using the book
profound effect on nursing education. Montag’s throughout the remainder of the century.
achievement also increased the shift of nursing edu- Henderson believed that nursing complemented
cation from the hospital to institutions of higher the patient by giving him or her what was needed in
learning. “will or strength” to perform the daily activities and
carry out the physician’s treatment. She believed
Virginia Henderson strongly in “getting inside the skin”of her patients as
a way of knowing what he or she needed.As she said,
Background “The nurse is temporarily the consciousness of the
Virginia Henderson was born November 30, unconscious,the love of life for the suicidal,the leg of
1897, in Kansas City, Missouri. She attended the the amputee, the eyes of the newly blind, a means of
U.S. Army School of Nursing during World War locomotion for the infant and the knowledge and
I. Her mentor was Annie Goodrich, head of the confidence of the new mother”(Henderson, 1955).
Army School. Goodrich later became the first Her beginnings were in public health, and this
dean of the Yale School of Nursing. After influenced her definition of nursing. Because of
the war, Henderson continued her nursing career this background, Henderson was a proponent of
in public health in New York City and publicly financed, universally accessible health-care
Washington, D.C. services. She understood that nurses maintained
Henderson decided to enter nursing education roots in the communities where they lived, and she
and took her first faculty position at the Norfolk believed that nursing belonged in the forefront of
Virginia Protestant Hospital School of Nursing. In health-care reform. She also believed that nurses
1929 she returned to New York and enrolled in should take every opportunity to advance the pro-
Columbia Teacher’s College to further her nursing fession by becoming leaders in developing plans for
education. Here she earned her bachelor’s and mas- implementing accessible health care. She founded
ter’s degrees and then joined the faculty of the Interagency Council on Information Resources
Columbia Teacher’s College. for Nursing. She was a consultant to the National
In 1953 she joined the faculty of the Yale School Library of Medicine and the American Journal of
of Nursing in New Haven,Connecticut,as a research Nursing Company. Henderson received many
associate and spent the last four decades of her life awards for her work and efforts to increase the sta-
there. She began a 19-year project to review nursing tus of the nursing profession.The Sigma Theta Tau
literature and published the four-volume Nursing International Nurses Honor Society named its
Studies Index, which indexed the English-language library in honor of her outstanding contributions to
nursing literature from 1900 through 1960. nursing.

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Contribution to 20th-Century Nursing ANA (in 1911), it continued to exclude men until
1930. One of the early acts of the organization was
Henderson is thought by many to be the most
to prevent men from practicing as nurses in the
important nursing figure in the 20th century. Her
military. The Army Nurse Corps, created in 1901,
colleagues refer to her as the 20th century Florence
barred men from serving as nurses (Brown, 1942;
Nightingale (ualberta.ca/~jmorris/nt/henderson.
Kalisch & Kalisch, 2004).
htm, 2000). She represents the essence and the
At the conclusion of the Korean War, the armed
spirit of nursing in the 20th century.
services again permitted men to serve as military
Men in Nursing nurses. Once men entered the military as nurses,
their numbers increased in civilian nursing as well.
Men are not new to nursing. Early Egyptian priests Nursing schools began to admit men, and the num-
who served the goddess Sekhmet practiced nurs- bers of men in nursing gradually increased. Today,
ing.The first nursing school in the world started in although still comparatively few,the number of men
India in about 250 B.C., and only men were consid- pursing nursing careers continues to increase. Men
ered “pure” enough for admission. are attaining graduate degrees and specialty certifi-
In the Byzantine Empire, nursing was practiced cation and continue to enhance nursing by resum-
primarily by men and was a separate profession ing their historical role as caring professionals.
(Kalisch & Kalisch,2004).During every plague that
swept through Europe, men risked their lives to Professional Organizations
provide nursing care. In 300 A.D. the Parabolani, a
group of men, started a hospital to care for victims ANA
of the Black Plague. Two hundred years later,
In 1896 delegates from 10 nursing schools’ alumnae
St. Benedict founded the Benedictine Nursing
associations met to organize a national professional
Order (Kalisch & Kalisch, 2004). Throughout the
association for nurses. The constitution and bylaws
Middle Ages, military, religious, and lay orders of
were completed in 1907, and the Nurses Associated
men continued to provide nursing care.
Alumnae of the United States and Canada was creat-
The Alexian Brothers, named after St. Alexis, a
ed.The name was changed in 1911 to the American
5th century nurse, were organized in the 1300s to
Nurses Association, which in 1982 became a federa-
provide nursing care to those affected by the Black
tion of constituent state nurses associations. In 1908,
Death. In 1863, the Alexian Brothers opened their
the Canadian Association of Nursing Education cre-
first hospital in the United States to educate men
ated the Canadian National Association of Trained
as nurses. The Mills School for Nursing and
Nurses, which became the Canadian Nurses
St. Vincent’s School for men were organized in
Association in 1924, with Mary Agnes Snively as its
New York in 1888. At that time, men did not
first president (Mansell & Dodd, 2005).
attend female nursing schools.
The purposes of the ANA are to:
Before the Civil War both male and female
slaves were employed as “nurses.” During the Civil 1. Foster high standards of nursing practice
War the Union used mainly female nurse volun- 2. Promote the rights of nurses in the workplace
teers, although some men also filled this responsi- 3. Project a positive and realistic view of nursing
bility.The poet Walt Whitman, for example, served 4. Lobby the Congress and regulatory agencies on
as a volunteer nurse in the Union Army. The health-care issues affecting nurses and the public
Confederate Army identified 30 men in each regi-
These purposes, reviewed during each biennial
ment to serve as military nurses. Charged with this
meeting by the House of Delegates, are unrestrict-
responsibility, these men tended to the ill on the
ed by consideration of age, color, creed, disability,
battlefields (Clay, 1928).
gender, health status, lifestyle, nationality, religion,
Modern nursing continued to develop as a pre-
race, or sexual orientation (ANA, 2007).
dominantly female profession, however, excluding
The goals of the Canadian Nurses Association
men from schools of nursing and the professional
are to:
organizations. The Nurses Associated Alumnae of
the United States and Canada held its first annual 1. Advance the discipline of nursing in the inter-
meeting in Baltimore in 1897. Later becoming the est of the public

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2. Advocate for policy that incorporates the prin- The registered care technician category was never
ciples of primary health care (access, interdisci- established despite the AMA’s vigorous support.
plinary, patient and community involvement, The ANA frequently publishes position state-
health promotion) and respects the Canada ments outlining the organization’s position on par-
Health Act ticular topics important to the health and welfare of
3. Advance the regulation of RNs in the interest the public and/or the nurse. Box 15-1 summarizes
of the public some of the current position statements available
4. Collaborate with nurses, other providers, stake- from the ANA, which can be accessed on the ANA
holders, and the public to achieve and sustain Web site (nursingworld.org/) or are available by
quality practice environments and positive mail on request. Likewise, the Canadian Nurses
client outcomes Organization publishes position statements on
5. Advance international health such issues as education, ethics, healthy public pol-
6. Promote awareness of the profession so that the icy,leadership,practice,primary health care,protec-
roles and expertise of RNs are understood, tion of the public, and research (Nursing Now,
respected, and optimized (abbreviated from 2005; 2007).
CAN-AIIC at http://www.CNA-nurses.ca) Finally, the ANA offers certification in various
specialty areas. Certification is a formal, voluntary
The core policy issues identified by the ANA in process by which the professional demonstrates
2007 were: knowledge of and expertise in a specific area of
practice. It is a way to establish the nurse’s expertise
■ Nursing shortage
■ Workplace rights beyond the basic requirements for licensure and is
■ Workplace health and safety an important part of peer recognition for nurses. In
■ Appropriate staffing many areas, certification entitles the nurse to salary
■ Patient safety and advocacy increases and position advancement. Some special-
ty nursing organizations also have certification pro-
Although more than 2 million people are mem- grams.
bers of the nursing profession in the United
States, only about 10% of the nation’s RNs are National League for Nursing
members of their professional organization. The Another large nursing organization is the National
many different subgroups and numerous specialty League for Nursing (NLN). Unlike ANA mem-
nursing organizations contribute to this fragmen- bership, NLN membership is open to other health
tation, which makes presenting a united front professionals and interested consumers. Over 1500
from which to advocate for nursing difficult. As nursing schools and health-care agencies and more
the ANA works on the goal of preparing nurses than 5000 nurses, educators, administrators, con-
during the 21st century, nurses need to work sumers, and students are members of the NLN
together in their efforts to identify and promote (nln.org/aboutnln/info-history.htm).
their unique, autonomous role within the health- The NLN participates in test services, research,
care system. and publication. It also lobbies actively for nursing
Many advantages are available to nurses who issues and is currently working cooperatively with
join the ANA. Membership offers benefits such as the ANA and other nursing organizations on
informative publications, group life and health health-care reform. To do such things more effec-
insurance, malpractice insurance, and continuing tively, the ANA, NLN, American Association of
education courses. As the major voice of nursing in Colleges of Nursing, and American Organization
the United States, the ANA lobbies the govern- of Nurse Executives have formed a coalition called
ment to influence laws that affect the practice of the TriCouncil for the purpose of dealing with
nursing and the safety of consumers. The power of issues that are important to all nurses.
the ANA was apparent when nurses lobbied The NLN formed a separate accrediting
against the American Medical Association’s agency, the National League for Nursing
(AMA) proposal to create a new category of Accrediting Agency (NLNAC). The NLNAC is
health-care worker, the registered care technician, responsible for the specialized accreditation of
as an answer to the nursing shortage of the 1980s. nursing education schools and programs, both

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box 15-1
Position Statements
American Nurses Association Healthy Nursing Work Hours for Registered Nurses in All
Bloodborne and Airborne Diseases Roles and Settings
Education and Barrier Use for Sexually Transmitted Pain Management and Control of Distressing Symptoms in
Diseases and HIV Infection Dying Patients
The Health Care Service System and Linkage of Primary Human Cloning by Means of Blastomere Splitting and
Care, Substance Abuse, Mental Health, and HIV/AIDS- Nuclear Transplantation
Related Services Social Causes and Health Care
AIDS/HIV Disease and Socio-Culturally Diverse Populations Elimination of Violence in Advertising Directed Toward
Equipment/Safety Procedures to Prevent Transmission of Children, Adolescents, and Families
Bloodborne Diseases Tobacco Use Prevention, Cessation, and Exposure to
Guidelines for Disclosure to a Known Third Party About Second-Hand Smoke
Possible HIV Infection Adult Immunization
HIV Infected Nurse, Ethical Obligations and Disclosure Adolescent Immunization
Tuberculosis and HIV Violence Against Women
HIV Disease and Correctional Inmates Adolescent Health
Needle Exchange and HIV Environmental Tobacco Smoke
Personnel Policies and HIV in the Workplace Prevention of Tobacco Use in Youth
Post-Exposure Programs in the Event of Occupational Use of Placebos for Pain Management in Patients with
Exposure to HIV/HBV Cancer
HIV Exposure from Rape/Sexual Assault Home Care for Mother, Infant, and Family Following Birth
HIV Infection and Nursing Students Promotion and Disease Prevention
Tuberculosis and Public Health Nursing Long-Term Care
HIV Infection and U.S. Teenagers Childhood Immunizations
HIV Testing Informal Caregiving
Travel Restrictions for Persons with HIV/AIDS Lead Poisoning and Screening
HIV Disease and Women Nutrition Screening for the Elderly
Ethics and Human Rights Reproductive Health
Stem Cell Research Drug and Alcohol Abuse
Privacy and Confidentiality Abuse of Prescription Drugs
Assuring Patient Safety: Registered Nurses’Responsibility Polypharmacy and the Older Adult
in all Roles and Settings to Guard Against Working When Opposition to Criminal Prosecution of Women for Use of
Fatigued Drugs While Pregnant
Assisted Suicide Drug Testing for Health-Care Workers
Nurses’Participation in Capital Punishment Nursing Education
The Non-Negotiable Nature of the ANA Code for Nurses Guideline for Commercial Support for Continuing Nursing
with Interpretive Statements Education
Cultural Diversity in Nursing Practice Nursing Practice
Discrimination and Racism in Health Care Professional Role Competence
Nursing Care and Do-Not-Resuscitate Decisions Safety Issues Related to Tubing and Catheter Misconnec-
Ethics and Human Rights tions
Active Euthanasia Assuring Safe, High-Quality Health Care in Pre-K Through
Foregoing Nutrition and Hydration 12 Educational Settings
Mechanisms Through Which SNAs Consider Ethical/Human Credentialing and Privileging of Advanced Practice Regis-
Rights Issues tered Nurses
Nursing and the Patient Self-Determination Acts Providing Patients Safe Access to Therapeutic
Marijuana/Cannabis
Risk and Responsibility in Providing Nursing Care
Privatization and For-Profit Conversion
Reduction of Patient Restraint and Seclusion in Healthcare
Settings A National Nursing Database to Support Clinical Nursing
Practice
Assuring Patient Safety: The Employers’Role in Promoting

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box 15-1
Position Statements—cont’d
Nurse-Midwifery Polygraph Testing of Health Care Workers
ANA Response to Pew Commission Report Sexual Harassment
Nursing Research Unlicensed Assistive Personnel (Note: ANA work on the
Education for Participation in Nursing Research UAP issue is ongoing)
Consumer Advocacy Registered Nurses Utilization of Nursing Personnel in All
Settings
Referrals to the Most Appropriate Provider
Registered Nurse Education Relating to the Utilization of
Mercury in Vaccines
Unlicensed Assistive Personnel
Elimination of Medication Waste in Long-Term Care Facilities
Joint Statements
Workplace Advocacy
Joint Statement on Delegation American Nurses Associ-
Assuring Patient Safety: The Employers’Role in Promoting ation (ANA) and National Council of State Boards of
Healthy Nursing Work Hours for Registered Nurses in All Nursing
Roles and Settings
Authentication in a Computer-Based Patient Record
Assuring Patient Safety: Registered Nurses’Responsibility in
All roles and Settings to Guard Against Working When On Access to Patient Data
Fatigued Computer-Based Patient Record Standards
Elimination of Manual Patient Handling to Prevent Work- Services to Families Following Sudden Infant Death Syn-
Related Musculoskeletal Disorders drome
Work Release During a Disaster: Guidelines for Employers Association of Operating Room Nurses Official Statement
on RN First Assistants
Registered Nurses’Rights and Responsibilities Related to
work Release During a Disaster Maintaining Professional and Legal Standards During a
Shortage of Nursing Personnel
Opposition to Mandatory Overtime
Role of the Registered Nurse in the Management of
Latex Allergy
Patients Receiving IV Conscious Sedation
The Right to Accept or Reject an Assignment
Role of the Registered Nurse in the Management of
Restructuring, Work Redesign, and the Job and Career Analgesia by Catheter Techniques
Security of Registered Nurses
post-secondary and higher degree (master’s degree, ■ Emphasis on lifelong learning
baccalaureate degree, associate-degree, diploma, ■ Continued interaction with colleges and univer-
and practical nursing programs). sities (noadn.org)

National Organization for American Academy of Nursing
Associate-Degree Nursing
The American Academy of Nursing consists of
Associate-degree nursing programs prepare the over 1500 nursing leaders in practice, education,
largest number of new graduates for RN licensure. management, and research. Its mission is to
Many of these individuals would never have had advance health policy and practice through the
the opportunity to become RNs without the access generation, synthesis, and dissemination of nursing
afforded by the community college system. The knowledge. The mission is accomplished through
move to begin a national organization to address Nursing Outlook, a professional journal; expert pan-
associate-degree nursing began in 1986. The els composed of members of the Academy, a
organization identified two major goals: to main- Scholar in Residence program, and supporting
tain eligibility for licensure for associate-degree appointment of nurses to key policy positions.
graduates and to interact with other nursing Membership is through nomination by current
organizations. Today, the mission of the National Fellows of the Academy (http://www.aannet.org).
Organization for Associate Degree Nursing
(NOADN) includes supporting the associate- National Institute for Nursing Research
degree graduate through:
The National Institute for Nursing Research
■ Strong educational programs (NINR), unlike the other associations described
■ Dynamic curricula and education of students in here, is an arm of the federal government, one of
a variety of settings the 27 institutes of National Institutes of Health

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(NIH). Originally a center at NIH, it became a As managed care plans grow and spread across
full-fledged insititute in 1993. NINR supports and the country, these companies become powerful
conducts basic and clinical research and provides enough to be able to negotiate reduced rates (dis-
research training in health promotion, disease and counts) from local hospitals (Trinh & O’Connor,
disability prevention, quality of life, health dispari- 2002). They can, in effect, say, “We can get an
ties, management of symptoms, and end-of-life appendectomy for $2300 at hospital A; why should
care encompassing the entire life span (http://www. we pay you $2700?” If hospital B does not agree,
ninr.nih.gov). the hospital may lose all the patients enrolled
in that managed care plan.This pressures hospital B
Specialty Organizations to reduce costs and spread staff even thinner than
before.
In addition to the national nursing organizations, Similar price pressures come from Medicare,
nurses may join specialty practice organizations Medicaid, and other health insurance companies.To
focused on practice areas (e.g., critical care, neuro- keep costs under control, some states have cut bene-
science, obstetrics) or special interest groups (e.g., fits for people receiving Medicaid (state-supported
male nurses, Hispanic, Philippine, Aboriginal health benefits for low-income people) (Pear, 2002).
nurses). These organizations provide nurses with With the upsurge in for-profit health plans and
information regarding evidence-based practice, the purchase of not-for-profit hospitals by for-
trends in the field, and approved standards of spe- profit companies, U.S. health care has become
cialty practice. Links to nursing organizations may increasingly “corporatized.”It was thought that this
be found at nursingsociety.org/career/nursing_orgs. would yield a highly efficient, responsive system
html or http://www.cna-nurses.ca (“the customer is always right”). That has not hap-
pened because the “customer” who pays for insur-
Health Care Today ance coverage is actually the employer or the gov-
ernment, not the individual patient. The care
Among the industrialized countries of the world, provided by the for-profits, in general, appears to
the United States is the only one that does not pro- be of lesser quality than the old not-for-profit or
vide basic health-care coverage to every citizen fee-for-service plans (Mechanic, 2002).
(Lieberman, 2003). Forty-seven million Americans There is a limit to the extent to which cost cut-
have no health insurance (ANA, 2008a), yet the ting can increase efficiency without endangering
United States has technologically advanced, highly patients. A series of important research studies has
sophisticated health care and spends more per shown that increasing the number of RNs provid-
capita (per person) than most countries. ing care in a hospital has a direct effect on improv-
If the United States has the most advanced ing the outcomes of patient care.
knowledge and equipment and spends a great For many years, the United States has been try-
deal of money on health care, then why the cause ing to fix its health-care system by applying patch-
for alarm? What is wrong? Why doesn’t everyone es over its worst cracks, but this has apparently not
have health-care insurance? Why are people so worked very well. Does the system need a major
worried about the quality of care? The answer is overhaul? Yes. But first, there needs to be a clear
complex. vision of what it should be and what it should do
For most people, health insurance comes (O’Connor, 2002).Whatever way that vision devel-
through their place of employment. One problem ops, it is certain that nurses will have an important
with this is that many employers are motivated to role in a future health-care system. As Aiken and
keep the cost as low as possible or transfer much of colleagues (2002) wrote, “nurses contribute impor-
the cost to the employee. Another problem is that tantly to surveillance, early detection and timely
if one loses one’s job, health insurance is also lost. interventions that save lives” (p. 18).
Managed care was originally designed to reduce The ANA, among others, has described the cur-
the amount spent on health care by emphasizing rent health-care system in the United States as
prevention. Some have said that it has become a “sick”and “broken”(ANA,2008a).As stated before,
way to limit choices and ration care (Mechanic, forty-seven million Americans, including 9 million
2002) rather than prevent illness. children, have no health-care insurance. Even

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worse, two-thirds of the working-age population O’Brien, 2007). Ninety-percent of nurses are still
have a health-care–related financial problem such female, although the number of men is gradually
as unpaid medical bills, being uninsured, or being increasing (Dougherty, 2008). Concerns about the
underinsured. A survey of over 26,000 Americans, supply of RNs and staffing shortages persist in
half of whom belonged to a union, found that 1 in both the United States and Canada.
3 had decided to do without care because of the The related issues of excessive workload, manda-
cost. Half had stayed in a job just to keep their tory overtime, scheduling, abuse, workplace vio-
health-care benefits. More than half reported that lence, and lack of professional autonomy contribute
their health-care insurance did not cover the care to these concerns (Villeneuve & MacDonald,
they needed at a price they could afford (Currie, 2006). On the bright side, there are also some indi-
2008b). More detail about the survey can be found cations of increasing interest in a nursing career as
at www.healthcaresurvey.aflcio.org salaries improve and job opportunities expand.
The quality of the care provided is a second major Safe staffing, defined as the appropriate number
concern. A 1999 report issued by the Institute of and mix of nursing staff, is a critical issue for nurs-
Medicine estimated that 100,000 deaths in hospitals es and the people who need their care. A series of
every year were due to errors that could have been research studies has demonstrated the importance
prevented (ANA, 2008a). Hospital-acquired drug- of adequate nurse staffing. There is powerful evi-
resistant infections have become a major problem, dence that nurses save lives: there is a 7% increase
having increased a hundredfold over the last 10 years in the likelihood of a patient dying within 30 days
or so. In 1993 there were 3000 hospital discharges of admission for each additional patient assigned to
that included a diagnosis of drug-resistant microor- a nurse (Aiken et al., 2002; Potter & Mueller,
ganism. In 2005 there were 394,000 of these 2007). Nurses cannot gain in-depth understanding
discharges (Currie, 2008a). of their patients, protect their patients, or catch
Additional concerns include fragmented, early warning signs of trouble if they are over-
impersonal care; failure to consider the whole per- whelmed by the number of patients for whom they
son when treating a problem; and continuation of are responsible. Adequate numbers of nurses affect
disease focus rather than prevention focus. patient mortality, length of stay, urinary tract infec-
Furthermore, the United States face what Buchan tions, fall rates, incidence of hospital-acquired
called a “demographic double whammy” of an pneumonia, and more. For further information, see
aging population that will need more health care www.safestaffingsaveslives.org
and, at the same time, an aging workforce
(Hewison & Wildman, 2008). Health Care in the Future
In Canada, a debate over privatization versus
Ideally, a new model of health care is needed that
public funding of health care continues (Villeneuve
offers the following:
& MacDonald, 2006). Health care is still illness-
and disease-focused as in the United States. ■ Holistic, person-centered care
Although there is interest in complementary and ■ Seamless connections across community, acute-
alternative treatments, they have not been integrat- care, and long-term care settings (Pogue, 2007)
ed into general care. Disparities in care of members ■ Elimination of health disparities
of minority groups threaten to increase if not ■ Guaranteed accessible, affordable care for
addressed more effectively. everyone (ANA, 2008b)
Global interconnectedness has brought new con- ■ Safe care that heals and does not harm the
cerns about how quickly and easily infectious diseases patient
can cross national borders. HIV, severe acute respira- ■ Equal support for prevention, health promotion,
tory syndrome, and the annual waves of influenza and mental health care
that cross the globe are just a few reminders. ■ Healthy environment from green buildings
(Trossman, 2007) to the elimination of air,
Nursing Today water, soil, and other forms of pollution
Issues specific to nursing reflect the problems and ■ Acknowledgement and addressing of global
concerns of the system as a whole. The average health concerns: global warming, hunger, poverty,
bedside RN is in her middle to late 40s (Lillis & and disease at home and in developing countries

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Nursing in the Future The following are some specific actions you can
take to exert leadership in improving health care:
Within the nursing profession, there is much work
to do. Cohen (2007) addressed the issue of the ■ Learn more about the health-care system and
image that many nurses present to their public. your role in it.
One is professional appearance and behavior. She ■ Join your professional association and specialty
quotes Dumont on the question of dress, particu- associations and support their efforts to improve
larly wearing uniforms covered with cartoon char- care.
acters: “You’re the only thing between the patient ■ Talk with everyone and anyone who will listen.
and death, and you’re covered in cartoons. No won- ■ Write letters to the editor, speak on local radio
der you have no authority.”The following are some and television programs, and participate in
additional suggestions to improve nursing’s image: online discussions.
■ Speak to local, state, and national representatives
■ Always introduce yourself as a nurse.
about these concerns.
■ Define professional appearance appropriate to
your workplace, and enforce it. In summary,be “visible and vocal”in your support of
■ Define professional behavior, and enforce it. nursing and improved health care (ANA, 2008a).
■ Take every opportunity to speak to the public
about nursing. Conclusion
■ Document what nurses do and how important
As nursing moves forward in the 21st century, the
they are (Cohen, 2007).
need for courageous and innovative nurse leaders is
What else can nurses do? It is important that greater than ever. Society’s demand for high-quality
more members of minority groups be brought health care at an affordable cost is a contemporary
into nursing so that nursing better reflects force for change.
the increasing diversity of the population. Nurses began in hospitals,moved to the commu-
Collaboration with colleagues in other health nity, moved back into the hospitals, and are now
professions is also vital to improving health care. seeing a move back to the community. Men were
Physicians, therapists, social workers, psycholo- the earliest nurses, then left the profession and have
gists, aides, assistants, and technicians are con- now returned, bringing with them new ideas and
cerned about the quality of care provided. Patients leadership abilities. Nursing has become as diversi-
and their families are also concerned and person- fied as the populations it serves. You will be the
ally affected by the quality of care provided. All Nightingales, Walds, Sangers, Mahoneys, Montags,
these groups together would have a stronger voice and Hendersons of the future; the creativity and
in health-care reform. dedication of these nurses are part of everyone.





Study Questions

1. Read Notes on Nursing: What It Is and What It Is Not by Florence Nightingale. How much of its
content is still true today?

2. If Margaret Sanger were alive, how do you think she would view the issue of teaching school-
children about AIDS?
3. What do you think Lillian Wald would say about the status of hospitals and health care today?

4. How do you think Florence Nightingale would deal with a physician who is verbally abusive to
the nursing staff?
5. If you had been Margaret Sanger, would you have decided to stop teaching women about birth
control? Explain your answer.

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6. What is your definition of nursing? How does it compare or contrast with Virginia Henderson’s
definition?
7. Review the mission and purpose of the ANA or another national nursing organization online.
Do you believe that nurses should belong to these organizations? Explain your answer.



Case Study to Promote Critical Reasoning

Alina went to nursing school on an Air Force scholarship. She has been directed to lead the
planning for establishing a comprehensive primary care and health promotion program clinic on
board NASA’s newest international space station. The crew is to remain on board the station for
6 months at a time. The crew will consist of military men and women from three countries.

1. What medical and nursing equipment should Alina plan to have in this center?
2. What would the physical environment on board need to have to satisfy Florence Nightingale and
Lillian Wald?

3. How do you believe Virginia Henderson would describe the role of the nurse in this environment?
4. Develop a possible nursing research topic for study in this situation.



References Haase, P. (1990). The origins and rise of associate degree nursing
education. Durham, N.C.: Duke University Press.
Aiken, L., Clarke, S.P., Sloane, D., Sochalski, J., et al. (2002). Henderson, V. (1966). The nature of nursing. New York: Macmillan.
Hospital nurse staffing and patient mortality, nurse burnout Henderson, V. (1955). ualberta.ca/-jmorris/nt/henderson.htm
and job dissatisfaction. Journal of the American Medical Retrieved on May 9, 2000, unc.edu/ehallora/henderson.htm
Association, 288(16), 1987–1993. Hewison, A., & Wildman, S. (2008). Looking back, looking
American Nurses Association. (2007). Retrieved on October 16, forward: Enduring issues in nursing management. Journal of
2007, from http://www.nursingworld.org/ Nursing Management, 16(1), 1–3.
FunctionalMenuCategories/About ANA.aspx Improving practice environment: Keeping up the momentum.
American Nurses Association. (2008a). Health reform: The 2008 (2007, April): Nursing Now: Issues and Trends in Canadian
elections and beyond. The American Nurse, September/ Nursing, Number 22.
October. Kalisch, P.A., & Kalisch, B.J. (2004). American nursing: A history.
American Nurses Association. (2008b). Safe staffing save lives. Philadelphia: Lippincott, Williams & Wilkins.
The American Nurse, March/April. Lieberman, T. (2003). Bruised and broken: The US health system.
Applegate, M. (1988). Associate degree nursing and health care. AARP Bulletin, 44(3), 3–5.
In Perspectives of Nursing 1987–1989, pp. 207–219. Lillis, K., & O’Brien, A. (2007, February 12). Salary survey 2007.
Beletz, E. (1974). Is nursing’s public image up-to-date? Nursing Advance for Nurses, pp. 11–18.
Outlook, 22, 432–435. Longfellow, H.W. (1868). The lady with the lamp. In Williams, M.
Brown, D. (1942). Men nurses in the U.S. Navy. American Journal (1975). How does a poem mean? Boston: Houghton Mifflin.
of Nursing, 42(5), 499–501. Mansell, D., & Dodd, D. (2005). Professionalism and Canadian
Bueheler-Wilkerson, K. (1993). Bring care to the people: Lillian nursing. In Bates, C., Bates, D., & Rousseau, N. (eds.) On all
Wald’s legacy to public health nursing. American Journal frontiers: Four centuries of Canadian nursing (pp. 197-211).
of Public Health, 83, 1778–1785. Ottawa: University of Ottawa Press.
Clay, V. (1928). Home life of a Southern lady. In Hart, Albert B. Mayer, S. (1994). Amelia Greenwald: Pioneer in international
(ed.). American History Told by Contemporaries (vol. 4, p. 244). public health nursing. Nursing and Health Care, 15(2), 74–78.
N.Y.: MacMillan. Mechanic, D. (2002). Sociocultural implications of changing
Cohen, S. (2007). The image of nursing: How do others see us? organizational technologies in the provision of care. Social
How do we see ourselves? American Nurse Today, 2(5), 24–26. Science and Medicine, 54, 459–467.
Currie, D. (2008a). Drug-resistant could lower costs. The Nation’s National League for Nursing. Retrieved on May 4, 2006, from
Health, 38(4), 4. http://www.nln.org/aboutnln/info-history.htm
Currie, D. (2008b). One in three forgo care because of cost. The National Organization of Associate Degree Nursing. Retrieved
Nation’s Health, 38(4), 8. on May 3, 2006, from noadn.org conventionstate.htm
Donahue, H.P. (1985). Nursing, the Oldest Art. St. Louis: C.V. Mosby. Nightingale, F. (1859). Notes on nursing: What it is and what it is
Dougherty, C. (2008, May 7). Slowdown’s side effect: More nurs- not. Reprinted 1992. Philadelphia: J.B. Lippincott.
es. Wall Street Journal, pp. D1, D8. Nursing leadership in a changing world. (2005, January).
Griffith, G.J., & Griffith, H.J. (1965). Jensen’s history and trends in Nursing Now: Issues and Trends in Canadian Nursing,
professional nursing, 5th ed. St. Louis: C.V. Mosby. Number 18.

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O’Connor, K. (2002, April 8). Healthcare in need of a fix. Modern Schuyler, C.B. (1992). Florence Nightingale. In Notes on nursing:
Healthcare, 27. What it is and what it is not. Philadelphia: J.B. Lippincott.
Pear, R. (2002, November 20). Report: Health system in crisis. Sigma Theta Tau International Nursing Honor Society. (2006).
Sun Sentinel, 3A. Retrieved on May 3, 2006, from
Pogue, P. (2007). The nurse practitioner role. Into the Future nursingsociety.org/career/nursing_orgs.html
Nursing Leadership, 20(2), 34–38. Trinh, H.Q., & O’Connor, S.J. (2002). Helpful or harmful? The
Potter, P., & Mueller, J.R. (2007). How well do you know your impact of strategic change on the performance of U.S.
patients? Nursing Management, 38(2), 40-41. urban hospitals. Health Services Research, 37(1), 145–171.
Roberts, M. (1937). Florence Nightingale as a nurse educator. Trossman, S. (2007). Who says it’s not easy being green? Nurses
American Journal of Nursing, 37, 775. and health care leaders promote healing, environmentally
Rogers, M.E. (1988). Nursing science and art: A perspective. friendly facilities. The American Nurse, 39(2), 1, 8.
Nursing Science Quarterly, 1, 99–102. Villeneuve, M., & MacDonald, J. (2006). Toward 2020: Visions of
Sanger, M. (1938). Margaret Sanger: An autobiography. New York: nursing. Ottawa: Canadian Nurses Association.
W.W. Norton.

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Codes of Ethics for Nurses





American Nurses Association Code the integrity of the profession and its practice,
of Ethics for Nurses and for shaping social policy.
1. The nurse, in all professional relationships, Approved July 2001. Web site: nursingworld.
practices with compassion and respect for the org/ethics/chcode. htm
inherent dignity, worth, and uniqueness of Reprinted with permission from American Nurses
every individual, unrestricted by considerations Association, Code of Ethics for Nurses with
of social or economic status, personal attributes, Interpretive Statements, ©2001 American Nurses
or the nature of health problems. Publishing, American Nurses Foundation/American
2. The nurse’s primary commitment is to the Nurses Association, Washington, DC.
patient, whether an individual, family, group, or
community. Canadian Nurse Association Code of
3. The nurse promotes, advocates for, and strives Ethics for Registered Nurses
to protect the health, safety, and rights of the The Code of Ethics for Registered Nurses (CNA,
patient. 2008) serves as a foundation for nurses’ ethical
4. The nurse is responsible and accountable for practice. CNA believes that the following seven
individual nursing practice and determines the values, which are described in the code, are central
appropriate delegation of tasks consistent with to ethical nursing practice. In the code each of
the nurse’s obligation to provide optimum these values is accompanied by a number of
patient care. responsibility statements, and together they out-
5. The nurse owes the same duties to self as to line the ethical practice that is expected of regis-
others, including the responsibility to preserve tered nurses. CNA believes that the quality of the
integrity and safety, to maintain competence, work environment in which nurses practice is also
and to continue personal and professional fundamental to their ability to practice ethically.
growth. 1. Providing safe, compassionate, competent
6. The nurse participates in establishing, main- and ethical care
taining, and improving health care environ-
ments and conditions of employment con- Nurses provide safe, compassionate, competent
ducive to the provision of quality health care and ethical care.
and consistent with the values of the profession 2. Promoting health and well-being
through individual and collective action.
7. The nurse participates in the advancement of Nurses work with people to enable them to attain
their highest possible level of health and well-
the profession through contributions to prac- being.
tice, education, administration, and knowledge
development. 3. Promoting and respecting informed deci-
8. The nurse collaborates with other health pro- sion-making
fessionals and the public in promoting commu- Nurses recognize, respect and promote a person’s
nity, national, and international efforts to meet right to be informed and make decisions.
health needs.
9. The profession of nursing, as represented by 4. Preserving dignity
associations and their members, is responsible Nurses recognize and respect the intrinsic worth
for articulating nursing values, for maintaining of each person.

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5. Maintaining privacy and confidentiality The nurse holds in confidence personal infor-
mation and uses judgment in sharing this infor-
Nurses recognize the importance of privacy and mation.
confidentiality and safeguard personal, family and The nurse shares with society the responsibility
community information obtained in the context of for initiating and supporting action to meet the
a professional relationship.
health and social needs of the public, in particular
6. Promoting justice those of vulnerable populations.
The nurse also shares responsibility to sustain
Nurses uphold principles of justice by safeguarding and protect the natural environment from deple-
human rights, equity and fairness and by promot- tion, pollution, degradation, and destruction.
ing the public good.
Nurses and Practice
7. Being accountable
The nurse carries personal responsibility and
Nurses are accountable for their actions and accountability for nursing practice, and for main-
answerable for their practice. Ethical nursing prac- taining competence by continual learning.
tice also involves endeavoring to address broad The nurse maintains a standard personal
aspects of social justice that are associated with health such that the ability to provide care is not
health and well-being. These aspects relate to the compromised.
need for change in systems and societal structures The nurse uses judgment regarding individual
in order to create greater equity for all. Nurses competence when accepting and delegating
should endeavor as much as possible, individually responsibility.
and collectively, to advocate for and work toward The nurse at all times maintains standards of
eliminating social inequities. The code contains personal conduct which reflect well on the profes-
thirteen statements entitled “ethical endeavors,” sion and enhance public confidence.
which are intended to guide nurses in this area. The nurse, in providing care, ensures that use of
These statements address the need for awareness technology and scientific advances are compatible
and action around such areas as social inequalities, with safety, dignity, and rights of people.
accessibility and comprehensiveness of health care,
and major health concerns (e.g., poverty, violence, Nurses and the Profession
inadequate shelter) as well as broader global con- The nurse assumes the major role in determining
cerns (e.g., war, violations of human rights, world and implementing acceptable standards of clinical
hunger). nursing practice, management, research, and educa-
Canadian Nursing Association. Web site: tion.
www.cna-nurses.ca The nurse is active in developing a core
Reprinted with permission from the Canadian research-based professional knowledge.
Nurses Association, 2008. The nurse, acting through professional organi-
The International Council of Nurses zations, participates in creating and maintaining
Code of Ethics for Nurses equitable social and economic working conditions
in nursing.
Nurses and People
The nurse’s primary professional responsibility is to Nurses and Co-Workers
people requiring nursing care. The nurse sustains a co-operative relationship with
In providing nursing care, the nurse promotes co-workers in nursing and other fields.
an environment in which the human rights, values, The nurse takes appropriate action to safeguard
customs, and spiritual beliefs of the individual, individuals when their care is endangered by a co-
family, and community are respected. worker or any other person.
The nurse ensures that the individual receives Approved 2000. Web site: cn.ch/ethics.htm
sufficient information on which to base consent for Used with permission International Council of
care and related treatment. Nurses, Geneva, Switzerland, copyright 2000.

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Standards Published by the

American Nurses Association*





■ Faith Community Nursing: Scope and ■ Scope and Standards of Hospice and Palliative
Standards of Practice Nursing Practice
■ Intellectual and Developmental Disabilities ■ Scope and Standards of Neuroscience Nursing
Nursing: Scope and Standards of Practice Practice
■ Neonatal Nursing: Scope and Standards of ■ Scope and Standards of Nursing Informatics
Practice Practice
■ Pain Management Nursing: Scope and ■ Scope and Standards of Pediatric Nursing
Standards of Practice Practice
■ Plastic Surgery Nursing: Scope and Standards ■ Scope and Standards of Pediatric Oncology
of Practice Nursing
■ School Nursing: Scope and Standards of ■ Scope and Standards of Practice for Nursing
Practice Professional Development
■ Scope and Standards for Nurse Administrators ■ Scope and Standards of Psychiatric-Mental
■ Scope and Standards of Addictions Nursing Health Nursing Practice
Practice ■ Scope and Standards of Public Health Nursing
■ Scope and Standards of College Health Practice
Nursing Practice ■ Scope and Standards of Vascular Nursing
■ Scope and Standards of Diabetes Nursing Practice
Practice ■ Standards of Addictions Nursing Practice with
■ Scope and Standards of Gerontological Selected Diagnoses and Criteria
Nursing Practice
■ Scope and Standards of Home Health Nursing *nursingworld.org/books/
Practice


























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Guidelines for the Registered

Nurse in Giving, Accepting,

or Rejecting a Work Assignment*





Registered Nurses, as licensed professionals, share Nursing Care Delivery
the responsibility and accountability along with Only a Registered Nurse (RN) will assess, plan
their employer to ensure that safe, quality nursing and evaluate a patient’s or client’s nursing care
care is provided. The scope of professional nurses’ needs. No nurse shall be required or directed to
accountability involves legal, ethical, and profes- delegate nursing activities to other personnel in
sional guidelines for assuring safe, quality patient a manner inconsistent with the Nurse Practice
care. Legal responsibility for the provisions, dele- Act, the standards of the Joint Commission on
gation and supervision of patient care is specified Accreditation of Health Organizations, the
in the Nurse Practice Act 464.001, and the ANA Standards of Practice or Hospital Policy.
Administrative Rules Chapter 59S.The American Consistent with the preceding sentence, the
Nurses Association (ANA) Code for Nurses with individual RN has the autonomy to delegate (or
Interpretive Statements (1985) guides ethical not delegate) those aspects of nursing care the
conduct and decision making of professional nurse determines appropriate based on the
nurses. The ANA Standards and Scope of patient assessment.
Practice (1997) provides a systematic application When a nurse is floated to a unit or area where
of nursing process for patient care management the nurse receives an assignment that is consid-
across patient care settings. In addition, the ANA ered unsafe to perform independently, the RN has
Restructuring Survival Kit (1996) suggests com- the right and obligation to request and receive a
mon strategies to assist the professional nurse modified assignment, which reflects the RN’s
facing assignment and delegation issues during level of competence.
reassignment and reorganization, temporary or The Florida Nurses Association (FNA), the
permanent. Lastly, the employer requirements for Florida Organization of Nurse Executives
safe, competent staffing are outlined in facility (FONE), and the FNA Labor Employee
policies and guidelines. Relations Commission (LERC) recognize that
Within ethical and legal parameters the nurse changes in the health care delivery system have
exercises informed judgment and uses individual occurred and will continue to occur,while empha-
competence and qualifications as criteria in seek- sizing the common goal to provide safe quality
ing consultation, accepting responsibilities and patient care. The parties also recognize that RNs
delegating nursing activities to others. The nurse’s have a right and responsibility to participate in
decision regarding accepting or making work decisions affecting delivery of nursing care and
assignments is based on the legal, ethical and pro- related terms and conditions of employment. All
fessional obligation to assume responsibility for parties have a mutual interest in developing sys-
nursing judgment and action. tems, which will provide quality care on a cost
The document offers strategies for problem efficient basis without jeopardizing patient out-
solving as the staff nurse, nurse manager, chief comes. Thus, commitment to measuring the
nurse executive and administrator practice within impact of staffing and assignments to patient out-
the complex environment of the health care comes is a shared commitment of all professional
system. nurses irrespective of organizational structure.
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Assignment Despite Objection “Supervision” - is the provision of guidance by a
(ADO)/Documentation of Practice qualified nurse and periodic inspection by the nurse
Situation (DOPS) for the accomplishment of a nursing task or activi-
ty, provided the nurse is qualified and legally enti-
Staff nurses today face often untenable assignments
tled to perform such task or activity.The supervisor
that need to be documented as such. Critical, clin-
may be the delegator or a person of equal or greater
ical judgment should be utilized when evaluating
licensure to the delegator.
the appropriateness of an assignment. Refusal to
accept an assignment without appropriate discus- Scenario
sion within the chain of command can be defined
■ Suppose you are asked to care for an unfamil-
as insubordinate behavior. Each Registered Nurse
iar patient population or to go to a unit for
should become familiar with organizational poli-
which you feel unqualified—what do you do?
cies, procedures and documentation regarding
■ Suppose you are approached by your supervisor
refusal to accept an unsafe assignment. ANA has
and asked to work an additional shift. Your
recently adopted a position statement and model
immediate response is that you don’t want to
ADO form available for use by SNA members.
work another shift—what do you do?
(Please contact Florida Nurses Association for
further information.) Such situations are familiar and emphasize the rights
and responsibilities of the RN to make informed
Staffng decisions. Yet all members of the health care team,
In the event a Registered Nurse determines in from staff nurses to administrator, share a joint
his/her professional opinion that he/she has been responsibility to ensure that quality patient care is
given an assignment that does not allow for appro- provided. At times, though, difference in interpreta-
priate patient care, he/she shall notify the tion of legal or ethical principles may lead to conflict.
Supervisor or designee who shall review the con- Guidelines for decision making are offered to
cerns of the nurse. If the nurse’s concerns cannot be assist RNs problem-solve work assignment issues.
resolved by telephone, the Supervisor or designee, Applications of these guidelines are presented in
except in instances of compelling business reasons the form of scenarios, examples of unsafe assign-
that preclude him/her from doing so, will then ments experienced by RNs.
come to the unit within four (4) hours of being Guidelines for Decision Making
contacted by the nurse to assess the staffing. Such
assessment shall be documented with a copy given The complexity of the delivery of nursing care is
to the nurse. Nothing herein shall prohibit a such that only professional nurses with appropriate
Registered Nurse from completing and submitting education and experience can provide nursing care.
a protest of assignment form. Upon employment with a health care facility, the
nurse contracts or enters into an agreement with
Nurse Practice Act, 1994, that facility to provide nursing services in a collab-
Administrative Rules Chapt. 59S, orative practice environment.
14.001 Definitions (4/29/96) It is the Registered Nurse’s Responsibility to:
“Assignments” - are the normal daily functions of ■ provide competent nursing care to the patient
the UAPs based on institutional or agency job ■ exercise informed judgment and use individual
duties which do not involve delegation of nursing competence and qualifications as criteria in
functions or nursing judgment. seeking consultation, accepting responsibilities
“Competency” - is the demonstrated ability to and delegating nursing activities to others
carry out specified tasks or activities with reason- ■ clarify assignments, assess personal capabilities,
able skill and safety that adheres to the prevailing jointly identify options for patient care assign-
standard of practice in the nursing community. ments when he/she does not feel personally
“Delegation”- is the transference to a competent competent or adequately prepared to carry out
individual the authority to perform a selected nurs- a specific function
ing task or activity in a selected situation by a nurse ■ refuse an assignment that he/she does not feel
qualified by licensure and experience to perform prepared to assume after appropriate consulta-
the task or activity. tion with supervisor

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It is Nursing Management’s Responsibility to: which the licensee knows or has reason to
know that he or she is not competent to
■ ensure competent nursing care is provided to
perform
the patient
■ performing, without adequate supervision, pro-
■ evaluate the nurse’s ability to provide special-
fessional services which the licensee is author-
ized patient care
ized to perform only under the supervision of a
■ organize resources to ensure that patients
licensed professional, except in an emergency
receive appropriate nursing care
situation where a person’s life or health is in
■ collaborate with the staff nurse to clarify
danger
assignments, assess personal capabilities, joint-
■ abandoning or neglecting a patient or client
ly identify options for patient care assignments
who is in need of nursing care without making
when the nurse does not feel personally com-
reasonable arrangements for the continuation
petent or adequately prepared to carry out a
of such care
specific function
■ failure to exercise supervision over persons who
■ take appropriate disciplinary action according
are authorized to practice only under the
to facility policies
supervision of the licensed professional
■ communicate in written policies to the staff
the process to make assignment and Of the above, the issue of abandonment or neg-
reassignment decisions lect has thus far proven the most legally devastat-
■ provide education to staff and supervisory ing. Abandonment or neglect has been legally
personnel in the decision making process defined to include such actions as insufficient
regarding patient care assignments and observation (frequency of contact), failure to
reassignments, including patient placement assure competent intervention when the patient’s
and allocation of resources condition changes (qualified physician not in
■ plan and budget for staffing patterns based upon attendance), and withdrawal of services without
patient’s requirements and priorities for care provision for qualified coverage. Since nurses at
■ provide a clearly defined written mechanism all levels most frequently act as agents of the
for immediate internal review of proposed employing facility, the facility shares the risk of
assignments, which includes the participation liability with the nurse.
of the staff involved, to help avoid conflict
Application of Guidelines for
Issues Central to Potential Dilemmas Are: Decision Making
Two clinical scenarios are presented for the RN to
■ the right of the patient to receive safe profes-
demonstrate appropriate decision making when faced
sional nursing care at an acceptable level of
with an unsafe assignment. Sometimes an example or
quality
two can help the RN objectively examine legal, ethi-
■ the responsibility for an appropriate utilization
cal and professional issues prior to making a final
and distribution of nursing care services when
decision. Additional resources are listed following the
nursing becomes a scare resource
scenarios.
■ the responsibility for providing a practice
environment that assures adequate nursing Scenario—A Question of Competence
resources for the facility, while meeting the
An example of a potential dilemma is when an
current socioeconomic and political realities of
evening supervisor pulls a psychiatric nurse to the
shrinking health care dollars
coronary care unit because of a lack of nursing
staff. The CCU census has risen and there is not
Legal Issues
additional qualified staff available.
Behaviors and activities relevant to giving, accept- Suppose you are asked to care for an unfamil-
ing, or rejecting a work assignment that could lead iar patient population or to go to a unit for which
to disciplinary action include: you feel unqualified—what do you do?
■ practicing or offering to practice beyond the 1. CLARIFY what it is you are being asked to do.
scope permitted by law, or accepting and ■ How many patients will you be expected to
performing professional responsibilities care for?

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■ Does the care of these patients require you and the facility have a responsibility for safe
to have specialty knowledge and skills in patient care.
order to deliver safe nursing care?
■ Will there be qualified and experienced 4. POINT OF DECISION/IMPLICATIONS:
RNs on the unit? If none of the options are acceptable, you are at
■ What procedures and/or medications will your final decision point.
you be expected to administer? a) Accept the assignment, documenting carefully
■ What kind of orientation do you need to your concern for patient safety and the process
function safely in the unfamiliar setting? you used to inform the facility (manager) of
2. ASSESS yourself. Do you have the knowledge your concerns. Keep a personal copy of this
and skill to meet the expectations that have documentation and send a copy to the manag-
been outlined for you? Have you had experi- er(s) involved.Once you have reached this deci-
ence with similar patient populations? Have sion it is unwise to discuss the situation or your
you been oriented to this unit or a similar unit? feelings with other staff or patients. Now you
Would the perceived discrepancies between are legally accountable for these patients. From
your abilities and the expectations lead to an this point, withdrawal from the agreed upon
unsafe patient care situation? assignment may constitute abandonment.
3. IDENTIFY OPTIONS and implications of b) Refuse the assignment, being prepared for
your decision. disciplinary action. Document your concern
a) If you perceive that you can provide safe for patient safety and the process you used to
patient care, you should accept the assignment. inform the facility (manager) of your con-
You would now be ethically and legally respon- cerns. Keep a personal copy of this documen-
sible for the nursing care of these patients. tation and send a copy to the nurse executive.
b) If you perceive there is a discrepancy between Courtesy suggests that you also send a copy to
abilities and the expectations of the assign- the manager(s) involved.
ment, further dialogue with the nurse super- c) Document the steps taken in making your
visor is needed before you reach a decision. At decision. It may be necessary for you to use
this point it may be appropriate to consult the the facility’s grievance procedure.
next level of management, such as the house
supervisor or the chief nurse executive. Scenario—A Question of an Additional Shift
An example of another potential dilemma is when
In further dialogue, continue to assess whether
a nurse who recognizes his/her fatigue and its
you are qualified to accept either a portion or the
potential for patient harm is required to work an
whole of the requested assignment. Also point out
additional shift.
options which might be mutually beneficial. For
Suppose you are approached by your supervisor
example, obviously it would be unsafe for you to
and asked to work an additional shift. Your imme-
administer chemotherapy without prior training.
diate response is that you don’t want to work
However, if someone else administered the
another shift—what do you do?
chemotherapy, perhaps you could provide the
remainder of the required nursing care for that 1. CLARIFY what it is you are expected to do.
patient. If you feel unqualified for the assignment ■ For example, would the additional shift be
in its entirety, the dilemma becomes more complex. with the same patients you are currently car-
At this point the RN must be aware of the ing for, or would it involve a new patient
legal rights of the facility. Even though the RN assignment?
may have legitimate concern for patient safety ■ Is your reluctance to work another shift
and one’s own legal accountability in providing because of a new patient assignment you do
safe care, the facility has legal precedent to initi- not feel competent to accept? (If the answer
ate disciplinary action, including termination, if is yes, then refer to the previous example, “A
you refuse to accept an assignment. Therefore, it Question of Competence.”)
is important to continue to explore options in a ■ Is your reluctance due to work fatigue, or do
positive manner, recognizing that both the RN you have other plans?

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■ Is this a chronic request due to poor sched- including termination, if you refuse to accept an
uling, inadequate staffing, or chronic absen- assignment. Therefore, it is important to continue
teeism? to explore options in a positive manner, recognizing
■ Are you being asked to work because there both you and the facility have a responsibility for
is no relief nurse coming for your present safe patient care.
patient assignment? Because your unit will
be short of professional staff on the next 4. POINT OF DECISION/IMPLICATIONS
shift? Because another unit will be short of a) Accept the assignment, documenting your
professional staff on the next shift? professional concern for patient safety and the
■ How long are you being asked to work—the process you used to inform the facility (man-
entire shift or a portion of the shift? ager) of your concerns. Keep a personal copy
of this documentation and send a copy to the
2. ASSESS yourself. nurse executive. Courtesy suggests that you
■ Are you really tired, or do you just not feel also send a copy to the manager(s) involved.
like working? Is your fatigue level such that Once you have reached this decision it is
your care may be unsafe? Remember, you unwise to discuss the situation of your feel-
are legally responsible for the care of your ings with other staff and/or patients.
current patient assignment if relief is not b) Accept the assignment, documenting your
available. professional concerns for the chronic nature
of the request and possible long-term conse-
3 IDENTIFY OPTIONS and implications of quences in reducing the quality of care.
your decision. Documentation should follow the procedures
a) If you perceive that you can provide safe outlined in (a).
patient care and are willing to work the addi- c) Accept the assignment, documenting your
tional shift, accept the assignment. personal concerns regarding working condi-
b) If you perceive that you can provide safe tions in which management decides the legit-
patient care but are unwilling to stay due to imacy of employee personal commitments.
other plans or the chronic nature of the This documentation should go to your man-
request, inform the manager of your reasons ager. You may wish to request a meeting with
for not wishing to accept the assignment. your manager to discuss the incident and your
c) If you perceive that your fatigue will interfere concerns regarding future requests.
with your ability to safely care for patients, d) Refuse the assignment, being prepared for
indicate this fact to the manager. disciplinary action. If your reasons for refusal
If you do not accept the assignment and the man- were patient safety or an imperative personal
ager continues to attempt to persuade you it may be commitment, document this carefully, includ-
appropriate to consult the next level of manage- ing the process you used to inform the facili-
ment, such as the house supervisor or the nurse ty (nurse manager) of your concerns. Keep a
executive. personal copy of this documentation and send
In further dialogue, continue to weigh your rea- a copy to the chief nurse executive. Courtesy
sons for refusal versus the facility’s need for an RN. suggests that you also send a copy to the
If you have a strong alternate commitment, such as manager(s) involved.
no child care, or if you seriously feel your fatigue e) Document the rationale for your decision. It
will interfere with safe patient care, restate your may be necessary to use the facility’s grievance
reasons for refusal. procedure.
At this point, it is important for you to be aware
of the legal rights of the facility. Even though you Summary
may have legitimate concern for patient safety and Two scenarios of how an RN may apply the guide-
your own legal accountability in providing safe lines for decision making in the actual work situa-
care, or legitimate concern for the safety of your tion have been presented. Staffing dilemmas will
children or other commitments, the facility has always be present and mandate that active commu-
legal precedent to initiate disciplinary action, nication between staff nurses and all levels of

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nursing management be maintained to assure ■ The Florida Nurses Association, the largest
patient safety.The likelihood of a satisfactory solu- statewide organization for registered nurses,
tion will increase if there is prior consideration of represents nursing in the governmental, policy
the choices available. This consideration of avail- making arena and maintains current informa-
able alternatives should include recognition that tion and publications relative to the nurse’s
professional nurses are intelligent adults who practice environment. Contact FNA or check
should be involved in the decision making process. out our website http://www.floridanurse.org
Professional nurses are accountable for nursing for the benefits and services of membership, as
judgments and actions regardless of the personal well as priorities and activities of the
consequences. Providing safe nursing care to the Association.
patient is the ultimate objective of the professional ■ The American Nurses Association serves as
nurse and the health care facility. the national clearing-house of information and
The Florida Nurses Association Labor and offers publications on contemporary issues,
Employment Relations Commission acknowl- including standards of practice, nursing ethics,
edges: as well as legal and regulatory issues. Contact
ANA for a complimentary copy of the
■ the Florida Organization of Nurse Executives
Publications Catalogue.
for input and collaboration in this document
■ ANA Survival Kit (1996) available through the
and the development of the previous 1989 edi-
American Nurses Association.
tion of this document.
■ ANA Basic Guide to Safe Delegation available
■ the Florida Nurses Association Labor and
through the American Nurses Association.
Employment Relations Commission for final
■ ANA Code of Ethics for Nurses (1998) available
preparation of the revised 1999 edition of this
through the American Nurses Association.
document.
■ ANA Standards and Scope of Practice (1997)
Resources available through the American Nurses
Association.
To maintain current and accurate information on
■ Nurse Practice Act (Florida Statutes 464,
accountability of registered nurses for giving,
January 1994) and Administrative Rules (59S).
accepting, or rejecting a work assignment, the fol-
■ Board of Nursing. A complimentary copy of
lowing resources are suggested:
the Nurse Practice Act is available to each
■ Health Care Facility: Nurses are encouraged to registered nurse upon request.
seek consultation with their nurse manager/
*Reproduced with permission of Florida Nurses
executives to discuss the facility’s missions and
Association, 1999, Orlando, Florida.
goals as well as policies and procedures.

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Index CikguOnline





A Alarm Appearance
in stress response, 198 in job interview, 232
Abandonment Alcohol use professional image and, 254
legal issues in patient, 263 as licensure violation, 36 Appropriateness
Abilities workplace, 185–186 in delegation, 124
as delegation criterion, 121, 123 Algorithms Artifact level
Acceptance letters in quality improvement, 137 in organizational culture, 59
job search, 225–226, 229f Allergy Assault
Accident latex, 181–183, 182t overview of, 26
patient safety and, 147 Alternative medicine workplace, 177
Accountability health-care resources and, 144 Assertiveness
in codes of ethics, 257–258 Ambulatory care center aggressiveness versus, 75
principle of, 47 organizational structure of, 63f Assessment
in standards of practice, 28 American Academy of Nursing, 251 in delegation, 118
Acknowledgment of others American Hospital Association in ethical dilemmas, 49–50, 50b
in effective communication, on nursing shortage, 145 in SBAR communication model,
75, 75t Patient’s Bill of Rights of, 27 80, 81t
Acting unlicensed assistive personnel survey in work assignment guidelines,
health-care reform and, 151–152 of, 119 262–265
in values clarification, 42, 42b American Nurses Association Assignment
Active listening Code of Ethics for Nurses of, 47, delegation of tasks and, 118–119,
in communication, 74, 74b 188, 257 120f, 126
in evaluative feedback, 84 on delegation, 116–117 despite objection, 262
Active resistance criteria for, 121 Nurse Practice Act definition of,
to change, 107, 107t definition of, 120–121 262
Addictions on disabled nurses’ rights, 189 refusal of, 163
workplace, 185–186 on disaster and terrorism readiness, Assignment sheets
Administrative law, 23, 24 189–190 in time management, 162
Advance directives Do Not Resuscitate orders and, 32 Assistants
in ethical dilemmas, 50 ergonomic guidelines of, 185 power sources of, 65
legal issues in, 32–33 on health-care crisis, 252–253 Assisted suicide
Advancement health-care reform agenda of, 151–152 as ethical issue, 52
career, 236 history of, 248 Associate degree nursing education
Adverse event on mandatory overtime, 187 history of, 246–247
patient safety and, 147 overview of, 248–249 Assumptions
African-American registered nurses position statements of, 249, in organizational culture, 59
Mahoney as first, 246 250b–251b Attitudes
Age publications of, 259 in effective leadership, 9
distributive justice and, 45–46 quality of care and, 139, 148b, 149 in new job, 235–236
Agencies on reporting questionable practices, Authoritarian leadership style, 6, 6t
quality and safety support from, 188–189, 189b Authority
148b, 148–150 safety and, 149, 174–175 as power source, 64
Agency for Healthcare Research and on sexual harassment, 181 Autocratic leadership style, 6, 6t
Quality on staffing ratios, 188 Automation
quality indicators of, 149 standards of practice of, 27, 139, 259 in time management, 166
Web site of, 148b unlicensed assistive personnel and, 188 Autonomy
Aggressiveness Americans With Disabilities Act in codes of ethics, 257–258
assertiveness versus, 75 disabled nurses’ rights and, 189 in empowerment, 65
Aging as statutory law, 22 principle of, 44
of population and nursing workforce, Anxiety Avoidance
145–146 as barrier to effective communication, in response to conflict, 93b
Agreements 75–76 Awareness
collective bargaining, 98–99, 99b
in work-related stress, 198 in stress management, 207, 207b
267

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B Bureau of State Boards of Nurse design in, 108–109, 109f
Examiners integration in, 109f, 110
Back injuries licensure examination of, 34–35, 35t personal, 110, 111t
workplace, 184–185 Bureaucracy planning in, 109, 109f
Background in organizational structure, 61b macro and micro, 104
in SBAR communication model, Burnout, 204–207 as natural phenomenon, 105
80, 81t causes of, 204–206, 205b personal, 110, 111t
Background questions consequences of, 206–207, 212 process of, 104f, 104–105
in job interview, 228–229 defined, 204 receptivity to, 105
Balance stages of, 204 resistance to, 105–108, 106f, 107t
burnout and, 206 Business sense Change-of-shift report
in effective leadership, 9, 9f in effective management, 16 information in, 77b, 77–79, 78f–79f
Bargaining Byrne Charting
collective, 67 Ethel, 245 by exception, 29
Battery time management and, 163, 166
overview of, 26 C Child abuse
Behavior as licensure violation, 36
Deutschman’s myths and stages of Canada Chief nursing officers
changing, 110, 111t code of ethics in, 257–258 delegation and, 118
feedback and, 82–84, 83b–84b health-care issues in, 253 Child labor
professional, 254 licensure of nurses in, 34, 36 Sanger and, 240, 245
in sexual harassment, 180b standards of practice in, 26–27 Choice
values in, 41 Canadian Nurses Association, 248–249 in code of ethics, 257
Behavioral theories Code of Ethics for Registered Nurses in problem solving, 94f, 95
of leadership, 6, 6t of, 257–258 in values clarification, 42, 42b
Belief Care allocation Chronological résumé, 222
in ethical dilemma assessment, 50 in care delivery models, 127 Circadian rhythms
in organizational culture, 59 Care delivery models shift rotation and, 187
in stress management, 207b, 208 delegation and, 126–127 Civil law
systems of, 42–43 types of, 127 overview of, 23–24
Beneficence Care environment Civil Rights Act
principle of, 44–45 organizational, 60 on sexual harassment, 180
Bill of Rights Career issues, 217–237 Clarification
Patient’s, 27 advancement as, 236 in informal negotiations, 97b, 97–98
United States Constitution, 22 critical first year as, 235–236 of values, 41–42, 42t
Bioethics. See also Ethics interview process as, 226–234, 234b in work assignment guidelines,
defined, 43 job choice as, 234–235 262–264
Biological variations job search letters as, 225–226, Clarity
cultural diversity and, 192–193 227f–230f in effective communication, 74, 75t
Bioterrorism job search preliminaries as, 218–220 Client advocates
readiness for, 189–190 myths in, 218 in ethical dilemmas, 51
Birth control overview of, 218, 236 Client care
Sanger and, 240, 245–246 researching potential employer as, delegation of, 115–129. See also
Bloodborne Pathogens Standard, 220–221 Delegation
183 résumé writing as, 221b, 221–225, historical trends and issues in,
Body language 223f, 224t 132–133, 133t
in job interview, 232 SWOT analysis and, 218–219 management of
Bolton Act of 1943, 246 unsuccessful job search as, 235 economics of, 132, 143–145, 144f
Brainstorming Causation models of care delivery in,
in problem solving, 95 as component of negligence, 24 126–127
Breach of duty Census of Fatal Occupational Injuries Nightingale on, 242–243
as component of negligence, 24 workplace violence and, 176 quality evaluation in, 136, 136f,
Breathing Centers for Disease Control and 139, 142, 142t
in stress management, 208–209 Prevention quality improvement in, 135–139,
Brewster in safety risk reduction, 174 140t–141t
Mary, 243 Certified nursing assistants risk management in, 142–143
Bullying delegation and, 117 organizational environment and, 60
as source of conflict, 93 Change, 103–112 time management in, 159–160,
as workplace violence, 179 comfort zone and, 104f, 104–105 163
Bureau of Labor Statistics feedback suggesting, 83b, 83–84 schedule for, 77–79, 78f
workplace violence and, 176–177 implementation of, 108–110

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Client information in effective leadership, 9f, 10 myths surrounding, 94
reporting of, 77–82 in ethical dilemmas, 50 problem-solving in, 94f, 94–96, 95b
change–of–shift report in, 77b, with health-care provider, 80–81, 81t signs of need for, 93b, 93–94
77–79, 78f–79f in job search, 220 Conflicts
to clients and families, 81–82 lawsuit prevention and, 28b, 28–29, 29t workplace, 92–100
interdisciplinary communication listening in, 74, 74b resolution of, 94f, 94–99, 96b–97b,
in, 80–81, 81t with physicians, 80–81, 81t 99b. See also Conflict resolution
team conferences in, 79–80 principles of effective, 74–75, 75t Confrontation
Client needs categories in quality improvement, 152 in response to conflict, 92b, 93, 93b
in NCLEX–RN examination, 34–35, quasi–intentional tort and, 23–24 in sexual harassment, 181
35t verbal and nonverbal, 74, 74b Congress on Nursing Practice
Client wishes Compassion code of ethics of, 47
in ethical dilemma assessment, 50, in code of ethics, 257 Consent
50b Compatibility implied, 28
Climate change delegation and, 124–125 informed, 27–28
Health–care trends and, 133 Compensation Contact dermatitis
Clinical expertise in job choice, 235 from latex, 181–182
in effective management, 16 Competence Context
Clustering of tasks autonomy and, 44 in change implementation, 109
in time management, 166 in codes of ethics, 257–258 Continuing education
Coaching delegation and, 121, 123 expertise enhanced by, 67–68, 68f
in effective management, 16f, 17 in empowerment, 65 Continuous quality improvement
Code of Ethics for Nurses With in work assignment guidelines, defined, 135–136
Interpretive Statements, 47 263–264 process of, 136, 136f
Code of Ethics Project, 47 Competency Contraception
Codes of ethics, 47, 257–258. See also Nurse Practice Act definition of, 262 Sanger and, 240, 245–246
Ethics Competition Contract components
Coercion in conflict, 93–94 in collective bargaining, 98
as power source, 65 in health-care economics, 144–145 Control
Collaboration Computerized adaptive testing in management theory, 14, 15f
in codes of ethics, 257–258 in NCLEX–RN examination, 34 Controlling leadership style, 6, 6t
in guidelines for work assignments, Computerized client information Coordination of assignments
262, 265–266 systems delegation and, 118–119, 120f, 126
Colleagues benefits of, 76, 76b Coordination of care
communication with, 76b–77b, confidentiality and, 46 delegation and, 118–119, 120f, 126
76–77 Computerized lists Coping skills
Collective bargaining in time management, 161–162 in adaptation to work-related stress,
case study of, 98, 99b Conferences 203, 203t
contract components in, 98 expertise enhanced by, 67, 68f as buffer against burnout, 207
empowerment through, 67 Confidentiality maladaptive, 202
pros and cons of, 98–99 in codes of ethics, 258 Core competencies
Combination résumé, 222 genetic information and, 53 of Institute of Medicine, 150–151,
Comfort zone laws protecting, 24–25 151b
change process and, 104f, 104–105 principle of, 46 Cost-consciousness
Commission on Workplace Advocacy, Conflict in effective management, 16
174–175 as learning experience, 92 in health-care crisis, 252–253
Commitment overview of, 92 Cost containment
in leadership, 8 workplace in health-care crisis, 252–253
to patient case studies of, 92, 92b, 95b, in health-care delivery, 143–146, 144f
in codes of ethics, 257–258 95–96, 98, 99b nursing shortage and, 146
in stress management, 207b, 208 signs of, 93b, 93–94 Cost sharing
Communication, 74–82 sources of, 92–93 in client care economics, 144
in adaptation to workplace, 203 Conflict resolution Courage
assertiveness in, 75 case studies of, 92, 92b, 95b, 95–96, in effective leadership, 9, 9f
barriers to effective, 75–76 98, 99b Cover letters
in care delivery models, 127 collective bargaining in, 98–99, 99b job search, 225–226, 227f
with colleagues, 76b–77b, 76–77 in effective management, 16f, 17 Creativity
cultural diversity and, 192 formal negotiation in, 98–99, 99b in designing change, 109
delegation and, 126–127 informal negotiation in, 92, 92b, in leadership, 5
in effective followership, 5 96b–97b, 96–98 in problem solving, 95

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Crisis management Design flaws E
avoidance of, 164 resistance to change and, 105–106
Critical pathways Detachment Economics
in quality improvement, 137–139 in burnout, 204 in care setting, 139
sample, 140t–141t Detention of client care, 132
Critical thinking as false imprisonment, 25–26 in collective bargaining contracts, 98
in effective leadership, 9f, 10 Deutschman’s myths and stages of in formal negotiations, 98
in quality improvement, 152 changing behavior, 110, 111t health-care system and, 143–146,
workplace climate and, 191 Devaluation reaction myth 144f
Crossing the Quality Chasm, 135, 135b of conflict resolution, 94 of sexual harassment, 180
Cultural diversity Diagnostic errors Education
in advance directive procedure, 32 patient safety and, 146b in advance directive procedure, 32
as barrier to effective communication, Diagnostic-related groups employability and, 219
76 in client care economics, 144 expertise enhanced by, 67–68, 68f
components of, 192–193 Dignity Henderson’s contribution to, 247–248
in ethical dilemma assessment, 50 in code of ethics, 257 Montag’s contribution to, 246–247
health-care trends and, 132 Dilemma Nightingale’s contribution to, 242
as source of conflict, 93 defined, 49 in résumé writing, 222, 224
workplace climate and, 192–193 Direct channels of surgical patients, 81–82
Culture in effective communication, 75, 75t workplace climate and, 191
organizational, 59–60 Direct delegation Effective leadership
of safety, 147b, 147–148 indirect versus, 117, 125, 126t behaviors in, 9f, 10–11
Direction setting qualities in, 8–10, 9f, 9t
D in leadership, 5 Efficiency
Directive leadership style, 6, 6t in delegation, 123–124
Decisional activities in scientific management theories, 14
in effective management, 16f, 17 in effective management, 17 in time management, 164, 166
Decision making Disagreement Elder abuse
in care delivery models, 127 in effective followership, 5 as licensure violation, 36
delegation grid in, 121, 121b, 123f Disasters Electronic health records
empowerment through, 65 readiness for, 189–190 benefits of, 76, 76b
in ethical dilemmas, 50–51 Disconfirming of beliefs confidentiality and, 25, 46
matrix for staffing, 188, 188t resistance to change and, 107 in time management, 166
value of involvement in, 190–191 Discussion leadership E–mail
in work assignment guidelines, in informal negotiations, 97, 97b in job search, 226, 231t
262–266 Disempowerment rules for, 76–77, 77b
Delegation contributors to, 65 Emotional intelligence
of client care, 115–129 Distributive justice in leadership, 7
barriers to, 125–126, 126t defined, 45 theory of, 7
criteria for, 121 Do Not Resuscitate order Emotions
models of care delivery in, components of, 32b in ethical dilemmas, 48–51
126–127 ethical issues in, 47 in informal negotiations, 97, 97b
need for, 119 legal issues in, 31–32 in resistance to change, 105
nursing process and, 118–119, Documentation Employee development
120f in advance directive procedure, 32 in effective management, 16f, 17
principles of, 116–118, 117b of health-care provider contact, 80 feedback in, 82
relationship-oriented concerns in, lawsuit prevention and, 28b, 28–29, Employee evaluation
124–125, 125b 29t–30t in effective management, 16f, 17
safety and, 120–121, 121b, 122f, of medical errors, 147 performance appraisal in, 85–86
123b of practice situation, 262 Employee wellness
task-related concerns in, 121, 123f, of sexual harassment, 181 in risk management, 143
123–124 time management and, 159 Employer demand
direct versus indirect, 117, 125, 126t Dominance nursing job growth and, 145
five rights of, 116–117, 117b as organizational goal, 61 Empowerment
Nurse Practice Act definition of, Drug use defined, 65
262 as licensure violation, 36 of nurses, 65–68
overview of, 116b, 116–118 workplace, 185–186 collective bargaining and, 67
supervision versus, 117 Durable power of attorney contributors to, 65
Democratic leadership style, 6, 6t legal issues in, 32–33 decision making and, 66
Demographics Duty of care emotional components of, 65
health-care changes and, 132 as component of negligence, 24 enhancing expertise and, 67–68, 68f

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health-care reform and, 151–152 autonomy as, 44 Fatigue
professional organizations and, 67 beneficence as, 45 mandatory overtime and, 33–34
shared governance and, 66–67 confidentiality as, 46 stress-related, 209
power versus, 65 fidelity as, 46 in work assignment guidelines,
End–of–life decisions justice as, 45–46 264–265
legal issues in, 31–33 laws versus, 43 Feedback, 82–85
Endorsement nonmaleficence as, 44–45 in adaptation to workplace, 203
licensure through, 35–36 veracity as, 46–47 in effective communication, 75, 75t
Energy theories of, 43 in effective leadership, 10
in adaptation to workplace, 203 values and, 39–56 guidelines for providing, 82t, 82–84,
in effective leadership, 9, 9f Eustress, 198, 199t 83b–84b
in time management, 161–162 Euthanasia objectivity in, 82t, 82–84, 83b
Environmental concerns as ethical issue, 52 observable behavior in, 84
in code of ethics, 257 Evaluation positive and negative, 83b–84b,
health-care trends and, 132–133 in delegation, 118 83–84
Environmental control in ethical dilemmas, 51–52, 52b return feedback in, 84, 84b
cultural diversity and, 192 of quality improvement, 136, 136f, timing of, 83, 84b
Environmental stressors, 198 152 purpose of, 82
Environmental tempo Evaluation of suggestions Felony
time management and, 159 in problem solving, 94f, 95 defined, 23
Equal Employment Opportunity Evaluative feedback, 84–85 Felony conviction
Commission need for, 85, 85b as licensure violation, 36
on sexual harassment, 180, 180b response to, 85 Fidelity
Equipment Evidence-based practice principle of, 46
in care setting, 139 in quality and safety initiatives, 150 Filing systems
latex, 182t Examination in time management, 162–163
Ergonomic injuries nursing licensure, 34–35, 35t Finances
workplace, 184–185 Exercise in care setting, 139
Errors in stress management, 210 career issues and, 219
medical, 146–147. See also Medical Exhaustion Five Rights of Delegation
errors in burnout, 204 of National Council of State Boards
Espoused beliefs in stress response, 198 of Nursing, 116–117, 117b
in organizational culture, 59 Expectations Fixed pie myth
Ethical culture burnout and, 204 of conflict resolution, 94
organizational, 48 in new job, 235–236 Florida Nurses Association
Ethical dilemmas. See also Ethics in stress management, 210 Labor and Employment Relations
assessment in, 49–50, 50b work-related stress and, 201t, 201–202 Commission of, 261, 266
current issues in, 52 Experience Flow sheets
defined, 49 as barrier to delegation, 125 in time management, 162
emotional component in, 48–51 in résumé writing, 222–224 Focus
evaluation in, 51–52, 52b Expertise in effective communication, 74, 75t
genetics and, 52–54 in effective management, 16 Followership
implementation in, 51 means of enhancing, 67–68, 68t components of effective, 5
planning in, 50–51 as power source, 64 defined, 5
professional, 48–49, 54 Extrinsic values overview of, 4
questions in, 49, 50b defined, 41 response to poor leadership in, 5,
technology and, 40, 52–54 11–12
Ethics, 39–56 F Formal negotiation
belief systems and, 42–43 Facilities in conflict resolution, 98–99, 99b
codes of, 47 as care setting, 139 Formal processes
defined, 43 Fairness organizational, 64
dilemmas in, 48–56. See also Ethical as delegation criterion, 124 Functional nursing care delivery model,
dilemmas in empowerment, 65 127
guidelines for work assignments and, False imprisonment Functional résumé, 222, 223f
261–266 defined, 25
in leadership, 9 overview of, 25–26 G
morals versus, 43 Falsification of documents Gender
organizational, 48 as licensure violation, 36 in assault victim blaming, 178b
overview of issues in, 40 Falsification of records as barrier to effective communication,
principles of, 43–47 lawsuits from, 23, 29 76
accountability as, 47

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in conflicting work-family demands, current status of, 252 Human service occupations
205–206 economic climate and, 143–146, burnout in, 205
conflicts from issues related to, 93 144f, 252–253 Hume
sexual harassment and, 179 future needs in, 253 ethical theories of, 43
Gene therapy history and overview of, 132–135, Humor
ethical issues in, 54 133t, 134b–135b in stress management, 211
General adaptation syndrome macro and micro changes in, 104
in stress response, 198 quality and safety in, 131–150. I
Generation of possible solutions See also Quality of care; Safety Identification of issues
in problem solving, 94f, 95 quality in codes of ethics of, 257–258 in problem solving, 94, 94f
Genetics reform in Identification of options
ethical issues in, 52–54 need for, 150–153, 151b, 252–253 in work assignment guidelines,
Globalization role of nursing in, 151–152 264–265
Health-care trends and, 132–133 Health insurance Impaired workers, 185–186
Goal setting in health-care crisis, 252–253 Implementation
in effective leadership, 9f, 10 Health Insurance Portability and of change, 108–110, 109f
ethical dilemmas and, 50 Accountability Act in delegation, 118
in time management, 160–161, confidentiality and, 24–25 in ethical dilemmas, 51
161b–162b Health-care organizations of solution, 94f, 95
Good Samaritan laws types of health care, 58–59 Implied consent
overview of, 24 Health-care pollution defined, 28
Goodrich workplace, 193 Incompetence
Annie, 247 Health-care providers in professional ethical dilemmas, 54
Government agencies communication with, 80–81, 81t Indirect delegation
patient safety quality and, 148b, types of orders written by, 81 direct versus, 117, 125, 126t
148–149 Health-care surrogate Inertia
Ground rule setting defined, 33 resistance to change and, 107
in informal negotiations, 97, 97b in ethical dilemmas, 44, 51 Informal negotiation
Growth HealthIT, 149 in conflict resolution, 92, 92b,
as organizational goal, 60 Henderson 96b–97b, 96–98
professional, 191 Virginia, 240, 247–248 Informal processes
Guidance Henry Street Settlement House, 240, organizational, 64
in management theory, 15, 15f 244 Information
Guided imagery Hepatitis in advance directive procedure, 32
in stress management, 209, 209b from needlestick injury, 183 health-care reform and, 151
Guidelines Herbert as power source, 66
in quality improvement, 137 Sydney, 242 withholding of, 45
Hicks v. New York State Department of Informational activities
H Health, 125–126 in effective management, 16f, 17–18
Hierarchy of needs
Hall Informed consent
John, 242 Maslow’s, 106, 106f autonomy and, 44
Handle with Care campaign, 185 Higgins in codes of ethics, 257–258
Harassment Margaret (Sanger), 244–246 procedure and form for, 27–28
sexual, 179–181, 180b Historical background in standards of practice, 27–28
Hardiness of health care, 132–135, 133t, Initiative
as buffer against burnout, 207 134b–135b in effective leadership, 9, 9f
Harm of nursing, 240–248 Injuries
as component of negligence, 24 Hospital Quality Initiative, 149 back, 184–185
delegation and potential for, 121, Hospitals needlestick, 183–184
122f Nightingale in reform of, 241–243 prevention of
principle of nonmaleficence and, nursing shortage in, 145 in risk management, 143
44–45 safety hazards in, 172–173, 173t repetitive stress, 185
Health Hostile environment Innovation
delegation and, 124 in sexual harassment, 180 workplace climate and, 191
promotion in codes of ethics of, Human Genome Project Innovative organizational structure, 62,
257–258 ethical issues in, 53–54 64f
stress management and, 208–211, Human immunodeficiency virus infec- Inspiration
209b–211b tion in leadership, 8
Health care from needlestick injury, 183 Institute for Healthcare Improvement
in Canada, 253 Human relations–based management on SBAR communication model, 80
theory, 14–15

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Institute of Medicine Job interviews, 226–234 Law
core competencies of, 150–151, 151b answering questions in, 227–232 assault and battery, 26
overview of, 134 appearance and body language in, civil, 23–28
priority areas of, 134b 232–233 confidentiality, 24–25
on quality and safety of care, asking questions in, 233 criminal, 23
134b–135b, 134–135, 146b, do’s and dont’s of, 233, 234b defined, 22
146–147, 175 follow-up to, 233 end-of-life decisions and, 31–33
Institutional standards of practice initial, 226–227 ethical principles versus, 43
development of, 27 preparation for, 226–227 false imprisonment, 25–26
Insurance second, 233–234 Good Samaritan, 24
in health-care crisis, 252–253 Job search health-care practice and, 189b
Integration choices in, 234–235 health-care trends and, 132
in change implementation, 109f, 110 interviews in, 226–234, 234b lawsuit prevention and, 28b, 28–29,
Integrity letters in, 225–226, 227f–230f 29t
in effective leadership, 9, 9f preliminaries in, 218–219 liability insurance and, 31
Interagency Council on Information résumé writing in, 221b, 221–225, malpractice, 27
Resources for Nursing, 247 223f, 224t malpractice suits and, 22, 24, 26, 28b,
Interdisciplinary conferences SWOT analysis in, 218–219 28–31, 29t
expertise enhanced by, 67, 68f unsuccessful, 235 mandatory overtime and, 33–34
Internal standards of practice Joint Commission methods of creating, 22–23
development of, 27 on importance of communication, 80 needlestick injury, 183
Internal tempo on quality improvement, 142–143, negligence, 24
time management and, 159 148b, 150 nursing licensure and, 34–36, 35t
International Center for Patient Safety, on risk management, 142–143 nursing practice and, 21–37, 189b
147b, 147–148 on safety,147b–148b,147–148,150,175 end-of-life decisions and, 31–33
International Council of Nurses Code on SBAR communication model, lawsuit prevention and, 28b,
of Ethics for Nurses, 258 80–81 28–29, 29t
Internet Journals licensure and, 34–36, 35t
in job search, 226, 231t expertise enhanced by, 68, 68f mandatory overtime and, 33–34
Interpersonal activities Judgment standards of practice in, 26–31,
in effective management, 16f, 16–17 values as, 40 28b, 29t–30t
Interpersonal skills Justice sexual harassment, 180
in effective leadership, 7, 10–11 in code of ethics, 258 slander and libel, 25
Interruptions principle of, 45–46 sources of, 22–23
time management and, 164, 166 Juvenile criminal offense standards of care in, 26
Interviews defined, 23 Lawsuits
in job search, 226–234, 234b. See also common actions leading to, 29
Job interviews K common causes of negligence in, 28,
Intrinsic values Kaiser Family Foundation 29t
defined, 41 on quality and safety, 149 liability insurance and, 31
Introductory rounds Kant prevention of, 28b, 28–29, 29t
in quality improvement, 152 deontological ethics of, 43 procedure for, 30–31
Intuition Kevorkian Leadership
in job interview, 233 assisted suicide and, 52 change and
time management and, 164 King’s College Hospital, 241 implementation of, 108–110,
Involuntary psychiatric hospitalization 109f
legal issues in, 26 L personal, 110
Isolation defined, 4
in burnout, 204 Labor market effective behaviors in, 10–11
nursing, 145–146 in effective management, 15–16
J Labor reform effective qualities in, 8–10, 9f, 9t
Sanger and, 244–245 in ethical culture, 48
Job analysis and redesign Laissez-faire leadership style, 6, 6t
in effective management, 16f, 17 Language followership and, 4–5. See also
Job descriptions as barrier to effective communication, Followership
peer review and, 87 76 management versus, 14t
Job dissatisfaction in effective communication, 75, 75t readiness for, 4
burnout and, 204 in résumé writing, 224, 224t response to poor, 5, 11–12
nursing labor market and, 146 Latex servant, 15
Job growth allergy to, 181–183 styles of, 6, 6t
nursing, 145 theories of, 5–8, 6t–7t
products containing, 182t

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Learning prevention of, 28b, 28–29, 29t Mental health
from conflicts, 92 reasons for, 29–30 stress management and, 211b,
delegation and, 124 standards of care and, 27 211–212
in effective followership, 5 Managed care Mentor
in effective leadership, 10–11 in client care economics, 144 in adaptation to workplace, 203, 203t
Legal issues. See also Law as macro change, 104 in new job, 236
delegation and, 125–126 principles of, 252 Microbial threats
in work assignment guidelines, 263 Management. See also Managers workplace, 186–187
Legal representation of client care, 135–139, 140t–141t, Mills School for Nursing, 248
in malpractice lawsuits, 30–31 142–145. See also Client care Mindell
Legibility leadership versus, 14t Fania, 245
in résumé writing, 222 overview of, 14 Misdemeanor
Legislation stress, 207–212, 212b defined, 23
Health-care trends and, 132 theories of, 14–15, 15f Models of care delivery
Letters Managers, 13–19. See also Management delegation and, 126–127
job search, 225–226, 227f–230f bad management styles of, 18t Monitoring
Liability behaviors of effective, 16f, 16–18 in effective management, 16f, 17–18
vicarious, 26 in conflict resolution, 92b, 95b, 95–98 Montag
Liability insurance interruptions and, 164, 166 Mildred, 240, 246–247
professional, 31 management theories used by, 14–15, Moral leadership theory, 8
Libel 15f MORAL model
overview of, 25f non-nurse, 160 in ethical dilemmas, 52, 52b
Licensed practical nurses power sources of, 65 Moral reasoning, 40
delegation and, 116, 119, 121, 123f, qualities of effective, 15–16 Morale
126–128 readiness for, 14 in management theory, 15, 15f
Licensure, 34–36 slander and libel suits and, 25 sexual harassment and, 180
defined, 34 tasks of, 14 Morals
delegation and, 125 Mandatory licensure ethics versus, 43
disciplinary action and, 36 permissive versus, 34 Motivation
examinations for, 34–35, 35t Mandatory overtime, 187 in leadership, 6–7, 7t
mandatory versus permissive, 34 legal implications of, 33–34 Muggings
multistate, 36 Maslow in workplace violence, 177
qualifications for, 34 hierarchy of needs of, 106, 106f Multistate Licensure Compact, 36
through endorsement, 35–36 McGregor Myers-Briggs Type Indicator, 219
violations of, 36 management theories of, 14–15, 15f
Limit setting Measurement tools N
in time management, 163–164 in quality improvement, 139, 142, Narcotics
List making 142t delivery systems of
in time management, 161 Medical errors time management and, 166
Listening identification and reporting of, 147 workplace abuse of, 185
in effective communication, 74, 74b Institute of Medicine on, 134, 134b, National Association of Colored
in effective followership, 5 146b, 146–147, 253 Graduate Nurses, 246
in effective leadership, 10 patient safety and, 146b, 146–147 National Center for Workforce Analysis
in job interview, 232–233 quality improvement and, 134, 134b, projections of, 218
Living will 138 National Committee for Quality
defined, 32 risk management and, 142–143 Assurance, 150
in ethical dilemmas, 50 Medical Errors and Patient Safety Web National Council of State Boards of
legal issues in, 32–33 site, 148b, 149 Nursing
Loss of interest Medical information delegation decision-making grid of,
in burnout, 204 in ethical dilemma assessment, 50 121, 121b, 123f
Loyalty Medical practice delegation defined by, 120
in fidelity, 46 nursing practice versus, 27 Five Rights of Delegation of,
Medical savings accounts 116–117, 117b
M in client care economics, 144 licensure defined by, 34
Medicare Prospective Payment System
Mahoney Multistate Licensure Compact of, 36
Mary Eliza, 240, 246 in client care economics, 144 NCLEX–RN examination of, 34–35,
Malpractice Medication errors 35t
defined, 24 lawsuit prevention and, 28–29, National Database of Nursing Quality
insurance against, 31 29t–30t Indicators, 148b, 149
lawsuits resulting from, 22, 24, 26, in malpractice lawsuits, 22, 24 National health coverage
28–31 MedQIC, 148–149 in client care economics, 145

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National Institute for Nursing ethical principle of justice and, 45–46 O
Research, 251–252 Nonmaleficence
National Institute for Occupational as ethical principle, 44–45 Objective
Safety and Health Non-nurse managers in résumé writing, 222, 224
on workplace stress reduction, time management and, 160 Observation
212–212 Nurse Practice Act, 261–262 expertise enhanced by, 68
National Institute of Occupational Nurse-client relationship Occupational injuries
Safety and Health lawsuit prevention and, 28 ergonomic, 184–185
in safety risk reduction, 172, 174, in quality improvement, 152 needlestick, 183–184
174b Nurse-physician relationship overview of, 172
National Labor Relations Act, 98 communication and, 80–81, 81t from workplace violence, 176–179
National League for Nursing, 34, 249, as source of conflict, 93 Occupational Safety and Health
251 Nurses Administration
National Nurses’ Society on Addictions, career issues in, 217–237. See also Bloodborne Pathogens Standard of,
186 Career issues 183
National Organization for Associate empowering, 65–68, 68f ergonomic guidelines of, 184–185
Degree Nursing, 251 guidelines for work assignments for, in safety risk reduction, 172–173, 173t
National Patient Safety Goals, 147 261–266 Opportunities
National Quality Measures increasing demand for, 146 as power source, 66
Clearinghouse, 149 power sources of, 65 in SWOT analysis, 219
National Safety Council, 172 registered. See Registered nurses Optimism
in safety risk reduction, 172 risk of violence to, 172, 176–179, in effective leadership, 9, 9f
NCLEX–RN examination 177b–179b Oral communication
for licensure, 34–35, 35t shortage of, 145–146, 206–207, in job search, 220, 232–233
study program for, 35 218 Organic organizational structure, 62, 64f
Needlestick Act, 183 time allocation of, 159–160 Organizations
Needlestick injuries in traditional hierarchical structure, characteristics of, 59–60
workplace, 172, 183–184 61, 62f–63f culture of, 59–60
Negative feedback workforce aging of, 146 empowerment through professional,
guidelines for, 82t, 83b–84b, 83–84 Nursing ethics. See also Ethics 67
Neglect defined, 48 ethics of, 48
legal issues in patient, 126 Nursing faculty goals of, 60–61
Negligence shortage of, 146 power and empowerment and, 58–68
malpractice and, 24 Nursing labor market processes in, 64
standards of care and, 27 in client care management, quality and safety support from,
Negotiation 145–146 148b, 148–150
in formal conflict resolution, 98–99, Nursing practice researching of, 220–221
99b changing health-care climate and, scenarios illustrating, 58, 66
in informal conflict resolution, 92, 252–253 structure of, 61b, 61–62, 62f–64f
92b, 96b–97b, 96–98 definitions of, 240, 247 types of health-care, 58–59
Neonatal care ethics and, 48–54 work-related stress addressed by,
ethical issues in, 45–46, 53 codes of, 257–258 211–212
Netiquette in ethical dilemmas, 49–52, 50b, Organizing work
rules for, 76–77, 77b 52b filing systems in, 162–163
Networking future goals in, 254 goal setting in, 160–161, 161b–162b
in adaptation to workplace, 203, 203t history of, 240–248 list making in, 161
career enhancement and, 220 honeymoon phase in, 200 long–term planning in, 162
in effective management, 16, 16f law and, 21–37. See also Law schedule and blocks of time in, 162
Nightingale medical practice versus, 27 Ornish diet
Florence, 240–243 men in, 248 as example of personal change, 110
on delegation, 116, 126 orientation programs in, 201 Outcomes
influence of, 240 reality shock in, 200 in quality improvement evaluation,
on management, 242–243 Nursing process 139, 142, 142t, 152
nursing goal of, 240 delegation and, 118–119, 120f Overtime
power of information and, 65 in resolution of ethical dilemmas, legal implications of, 33–34
Noise 49–52, 50b, 52b mandatory, 187
as barrier to effective communication, Nursing Studies Index, 247 P
75 Nursing values
Nondirective leadership style, 6, 6t in codes of ethics, 257–258 Participative leadership style, 6, 6t
in effective management, 17 Nutrition Passive resistance
Nondiscrimination in stress management, 210, 210b to change, 107, 107t

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Patient abandonment and neglect Physical health in adaptation to work-related stress,
legal issues in, 263 in stress management, 208–210, 202–203, 203t
Patient care. See also Client care 209b–211b in conflict resolution
delegation of, 116–128. See also Physicians case study of, 95b, 95–96
Delegation communication with, 80–81, 81t process of, 94f, 94–95
Patient Care Partnership, 27 informed consent obtained by, in effective leadership, 9f, 10
Patient commitment 27–28 expertise enhanced by, 68, 68f
in codes of ethics, 257–258 types of orders written by, 81 Processes
Patient safety Physiological stressors, 198 organizational, 64
in codes of ethics, 257–258 Planning in quality improvement evaluation,
Institute of Medicine on, 134b, in change implementation, 109, 139, 142t
134–135, 146b, 146–147 109f Professional considerations and issues,
Joint Commission on, 147b, in delegation, 118 1–68, 169–255
147–148 in effective management, 16f, 17 leadership and followership as, 3–12
organizational culture and, 59–60 in ethical dilemmas, 50–51 management as, 13–19
in work assignment guidelines, health-care reform and, 151 nursing career as, 217–237, 239–255
261–266 in quality improvement, 136–137, nursing practice and law as, 21–37
Patient Self–Determination Act of 137b, 152 organizations, power, and empower-
1990 in time management, 162 ment as, 57–69
life-sustaining treatment and, 32 Polio epidemic union membership and, 98–99
nursing implications of, 33 mechanical ventilation and, 40 values and ethics as, 39–56, 257–258
as statutory law, 22 Pollution workplace as, 171–194
Patient’s Bill of Rights, 27 Health care, 193 work-related stress and burnout as,
Peer review Positive feedback 197–214
comprehensive system of, 87 guidelines for, 82t, 83b, 83–84 Professional development
fundamentals of, 86–87 Post–acute care reform plan, 149 job choice and, 234
Peer support Potential employer workplace climate and, 191
value of, 190 researching, 220–221 Professional identity
Performance appraisal Power, 64–65 development of, 203
procedure for, 85–86 conflict and, 93 threats to
standards for evaluation in, 86 defined, 64 resistance to change and, 106–107
Performance standards empowerment versus, 65 as source of conflict, 93
peer review and, 87 resistance to change and, 106–107 Professional negligence
Permissive leadership style, 6, 6t sources of, 64–65 malpractice as, 24
Permissive licensure Preventive errors Professional organizations, 248–252. See
mandatory versus, 34 patient safety and, 146b also specific organizations
Perseverance Primary nursing care delivery model, empowerment through, 67
in effective leadership, 9, 9f 127 specialty, 252
Personal change Principalism Professional practice committee
myths surrounding, 110, 111t in ethics, 43 in peer review, 87
stages of, 110, 111t Principles and Practice of Nursing, 247 Professional questions
Personal digital assistants Priorities in job interview, 229–232
in time management, 162 in delegation, 123 Professional values
Personal factors in time management, 160–161, 166, defined, 41
in burnout, 205–206 167t work realities versus, 201t, 201–203
Personal questions Privacy Professionalism
in job interview, 232 in codes of ethics, 258 in codes of ethics, 257–258
Personal space negative feedback and, 82t, 83, 83b image of nursing and, 254
cultural diversity and, 192 Private for-profit health-care organiza- Profit
invasion of, 93 tions as organizational goal, 60–61
Personal time inventory defined, 59 Promotion
in time management, 161 Private not-for-profit health-care peer review and, 87
Personal values organizations performance appraisal and, 86
defined, 41 defined, 59 Protocols
Personalized patient worksheet, 119, Prizing in quality improvement, 137
120f in values clarification, 42, 42b Psychiatric hospitalization
Physical barriers Problems legal issues in, 26
to effective communication, 75 workplace conflicts and, 91–100. See Psychological stressors, 198
Physical environment also Conflicts; Problem solving Psychosocial factors
workplace climate and, 193 Problem solving in ethical dilemma assessment, 50, 50b

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in resistance to change, 106, 106f, Recognition Resistance
108 in empowerment, 65 in stress response, 198
Public relations feedback for, 83 Resistance to change, 105–108
in effective management, 16f, 18 Recommendation lowering of, 107–108
Publicly supported health–care in SBAR communication model, 80, planning and, 109, 109f
organizations 81t recognition of, 107, 107t
defined, 59 Record-keeping sources of, 105–107
patient safety quality and, 148b, time management and, 163, 166 Resolution
148–149 Reframing of ethical dilemmas, 49–54, 50b, 52b
Punishment in stress management, 211–212 in response to conflict, 93b, 93–96,
in effective management, 16f, 17 Refreezing 94f. See also Conflict resolution
in management theory, 14, 15f in change process, 104f, 104–105 Resource allocation
Refusal of assignment distributive justice and, 40, 45–46
Q in limit setting, 163 in effective management, 16f, 17
procedure for, 261–266 in health-care delivery, 143–144
Quality chasm report
of Institute of Medicine, 135, Refusal of treatment as source of conflict, 93
135b battery and, 26 Respect
Quality of care in ethical dilemma, 51 in advance directive procedure, 32
defined, 135 informed consent and, 28 in code of ethics, 257
delegation and, 126 Registered nurses in cultural diversity, 193
evaluation of delegation and, 116–128. See also in effective leadership, 10
outcome in, 139, 142, 142t Delegation Response
process in, 139, 142t shortage of, 145–146 to conflict, 92
structure in, 139, 142t time management and, 159–160 to stress, 198–200, 199t
improvement of work assignment guidelines for, Responsibility
continuous, 135–136, 136f 261–266 in guidelines for work assignments,
evaluation of, 136, 136f, 139, 142, in assignment despite objection, 262–263
142t 262 Restraints
goals in, 135, 135b decision making in, 262–266 as false imprisonment, 25–26
organizational, 135–139, documentation of practice standards of practice and, 25–26
140t–141t situation and, 262 Résumé writing, 221–225
risk management in, 142–143 legal issues in, 263 education in, 222, 224
structured care methodologies in, Nurse Practice Act and, 261 grammar and syntax in, 222
137–138 nursing care delivery and, 261 language use in, 224, 224t
synonyms for, 135 resources for, 266 legibility in, 222
Institute of Medicine on, 134b–135b, Regulations length of, 222
134–135, 253 Health-care trends and, 132 objective in, 222, 224
Joint Commission on, 142–143 in health-care economics, 144–145 other components in, 224–225
organizational Rejection letters reasons for preparing, 221b
critical pathways in, 137–139, job search, 225–226, 230f skills and experience in, 222–224
140t–141t Relationship-oriented concerns types of, 222
strategic planning for, 136–137, in delegation, 124–125, 125b Rewards
137b Relaxation in effective management, 16f, 17
organizations supporting, 148b, in stress management, 209, 209b in empowerment, 65
148–150 Religion in management theory, 15, 15f
safety and, 134b–135b, 134–135, science and, 42–43 as power source, 64
142–143. See also Safety Repetitive stress injuries workplace climate and, 191
Quasi–intentional tort workplace, 185 Rhythm mode
overview of, 23–24 Reports in time management, 166–167, 167t
slander and libel as, 25 of client information, 77b, 77–82, Risk management
Questionable practices 78f–79f, 81t in quality improvement, 142–143
reporting of, 188–189, 189b of medical errors, 147 Risk taking
Quid pro quo of questionable practices, 188–189, in effective leadership, 4, 9
in sexual harassment, 180 189b Rogers
of sexual harassment, 181 Martha, 240
R time management and, 162 Root cause analysis
of workplace violence, 179 in quality and safety improvement,
Reality shock Research 147
work–related stress and, 200 expertise enhanced by, 68, 68f Rotation of shifts
Reasoning Research–based knowledge implications of, 187
moral, 40 in code of ethics, 258

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S Schiff Speech
Jacob, 244 quasi-intentional tort and, 25
Safe staffing, 253 Science Spokesperson status
Safety religion and, 42–43 in effective management, 16f, 17
in codes of ethics, 257–258 Scoping the situation Staffing
conflict from threats to, 93 in informal negotiations, 96b, 96–97 assessment in assignment despite
delegation and, 120–121, 121b, 122f, Security objection of, 262
123b conflict from threats to, 93 in care setting, 139
in guidelines for work assignments, Self-awareness collective bargaining and, 98–99, 99b
263–266 in effective leadership, 9, 9f delegation and preferences in, 125,
Institute of Medicine on, 134b–135b, Self-determination 125b
134–135, 146b, 146–147 in empowerment, 65 ratios of, 188, 188t
organizational culture of, 59–60 Self-nurturing safe, 253
programs promoting, 175–176 in stress management, 211 time management and, 159
quality of care and, 134b–135b, Semantic barriers Standard résumé, 222
134–135, 142–143 to effective communication, 76 Standards of care
risk reduction and Sentinel event strategies, 147 defined, 26
American Nurses Association in, Sentinel events in quality improvement, 137, 143
149, 174–175 in risk management, 142–143 Standards of practice
Centers for Disease Control and Serious incidents accountability as, 28
Prevention in, 174 in risk management, 142 establishment of, 27
culture of safety in, 147b, 147–148 Servant leadership legal issues in, 26–31, 28b, 29t–30t
government agencies in, 148b, principles of, 15 accountability as, 28
148–149 Service occurrences informed consent as, 27–28
Institute of Medicine in, in risk management, 142 negligence malpractice suits and,
134b–135b, 134–135, 146b, Severe acute respiratory syndrome 27
146–147, 175 workplace, 186 nursing boards and, 26–27
Joint Commission in, 147b, Sexual harassment Patient’s Bill of Rights as, 27
147–148, 175 workplace, 179–181, 180b restraining patients and, 26
National Institute of Occupational Shared governance State Board Test Pool Examination, 34
Safety and Health in, 172, 174, empowerment through, 66–67 Status
174b Sharing as organizational goal, 61
nonprofit organizations in, 148b, in effective followership, 5 Strategic planning
149–150 of information in quality improvement, 136–137,
Occupational Safety and Health resistance to change and, 107 137b
Administration in, 172–173, Shift rotation Streamlining of work
173t implications of, 187 in time management, 164, 165f,
professional organizations in, 148b, Shortage 166–167, 167t
149 nursing, 145–146, 206–207, 218 Strengths
quality organization in, 148b, 150 Single–payer health coverage in SWOT analysis, 218–219
SBAR communication model and, in client care economics, 145 Stress
80–81, 81t Situation benefits of, 199–200
staffing requirements for, 253 in SBAR communication model, 80, continuum of response to, 198–200,
threats to 81t 199t
resistance to change and, 106, 108 Skills defined, 198
workplace, 172–173, 173t mastery in new job of, 236 management of, 207–212, 212b
in work assignment guidelines, in résumé writing, 222–224 in effective leadership, 9, 9f
261–266 Slander mental, 210–211, 211b
workplace, 171–176, 173t, 174b overview of, 25 organizational approaches to,
Salary Sleep 211–212
job choice and, 235 in stress management, 209 physical, 208–210, 209b–210b
job interview and, 231 Social organization self-assessment in, 207b–208b,
Sanger cultural diversity and, 192–193 207–208
Margaret, 240 workplace, 190–191 sources of, 198, 200t
SBAR model Social stressors, 198 work-related, 197–214
in communication with health-care Socializing adaptation to, 200–203, 203t
provider, 80–81, 81t in stress management, 211 burnout and, 204–207, 205b
Schedules time management and, 163 delegation and, 125
in time management, 162 Societal issues in response to change, 109–110
Schiavo case Health-care trends and, 132 in response to conflict, 92
as ethical issue, 52

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Structure Threats United States
organizational, 61b, 61–62, 62f–64f to professional identity health-care crisis in, 150–153, 151b,
in quality improvement evaluation, resistance to change and, 106–107 252–253
139, 142t as source of conflict, 93 health-care history in, 132–135, 133t,
Structured care methodologies to safety and security 134b–135b
in quality improvement, 137–138 defined, 177 United States Supreme Court
Substance abuse resistance to change and, 106 on nurses as supervisors, 189
workplace, 185–186 as source of conflict, 93 on sexual harassment, 180
Supervision workplace violence as, 176–179, Unlicensed assistive personnel
delegation and, 117–118 177b–179b American Nurses Association and,
delegation versus, 117 in SWOT analysis, 219 119
Nurse Practice Act definition of, 262 Time log delegation and, 116–119, 122f, 123f,
in work assignment guidelines, in time management, 164, 165f 125–128
262–263 Time management, 157–168 utilization of, 188
Supervisory support computers and, 158–159 Unnecessary work
value of, 190 cultural diversity and, 192 elimination of, 163–164
Support direct client care and, 159 Unsafe staffing complaint
in adaptation to workplace, 203, 203t documentation and, 159 for understaffing, 163
in effective followership, 5 fallacies in, 159 Utilitarianism
as power source, 66 limit setting in, 163–164 in ethics, 43
in sexual harassment, 181 organization in, 160–163,
in stress management, 211 161b–162b V
value of peer and supervisory, 190 overview of, 158 Value systems
Survival rhythm model in, 166–167, 167t components of, 41
as organizational goal, 60 schedule for, 77–79, 78f Values
SWOT analysis staff makeup and, 159–160 as barrier to effective communication,
in job search, 218–219 streamlining in, 164, 165f, 166–167, 75
in quality improvement, 137 167t clarification of, 41–42, 42t
time log in, 164, 165f defined, 40
T time perception in, 158b, 158–159 as determinants of behavior, 41
time-wasting activities and, 161,
Task nursing care delivery model, 127 development of, 41
Task versus relationship theory 161b ethics and, 39–56
of leadership, 6 Tort law. See also specific issues codes of, 257–258
Tasks overview of, 23–24 in ethical dilemma assessment, 50,
conflict from assignment of, 93 Total client care delivery model, 127 50b
delegation of, 121, 123f, 123–124 Traditional hierarchical structure extrinsic, 41
Team approach organizational, 61b, 61f–63f, 61–62 intrinsic, 41
in client information conferences, Trait theories moral reasoning and, 40
79–80 of leadership, 5 personal, 41
in quality improvement, 136f, Transformational leadership theory, 8 professional, 41
136–137, 137b Treatment errors systems of, 41
Team nursing care delivery model, 127 patient safety and, 146b Veracity
Technology Treatment goals as ethical principle, 46–47
burnout and, 206 in ethical dilemmas, 50 Verbal physicians’ orders
in client care trends, 132 TriCouncil telephone, 81
in code of ethics, 258 focus of, 249 Vicarious liability
confidentiality and, 46 Truth in malpractice, 26
in ethical dilemmas, 40, 52–54 as ethical principle, 46–47 Violence
time management and, 158–159, Tuberculosis workplace, 172, 176–179, 177b–179b
166 workplace, 186–187 blaming the victim of, 178, 178b
Telephone orders U categories of, 177
physician, 81 clues to potential for, 177–178,
Terminal condition Unfreezing 178b
defined, 33 in change process, 104f, 104–105 incidence of, 176–177
Territoriality Uninsured and underinsured workers, negative organizational outcomes
as source of conflict, 93 252–253 of, 177b
Terrorism Unions protection against, 178–179, 179b
readiness for, 189–190 in collective bargaining, 98–99, 99b Virtue ethics, 47–48
Thank you letters conflicts with management of, 93 Vision
job search, 225–226, 228f pros and cons of, 98 in effective leadership, 8, 10

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Voluntary psychiatric hospitalization Working relationships microbial threats to, 186–187
legal issues in, 26 in new job, 236 needlestick injuries in, 172, 183–184
value of, 190–191 overview of, 172, 193–194
W Working within organizations, 71–168. peer review in, 86–87
See also Workplace performance appraisal in, 85–86
Wald
Lillian, 240, 243–244 delegation of client care in, 115–129 physical environment in, 193
Weaknesses problems and conflicts in, 91–100 professional environment in, 191
in SWOT analysis, 219 process of change and, 103–113 reporting of client information in,
Web sites quality and safety in, 131–153 77b, 77–82, 78f–79f, 81t
of organizations promoting quality time management in, 157–168 reporting of questionable practices in,
and safety, 148b working together in, 73–88 188–189, 189b
Wellness center Workload rotating shifts in, 187
nontraditional structure of, 62, 64f conflict from increased, 93 safety in, 171–176, 173t, 174b. See
Withdrawal in empowerment, 65 also Safety
in burnout, 204 Workplace. See also Working within sexual harassment in, 179–181,
Work assignment guidelines organizations 180b
for registered nurses, 261–266 burnout in, 204–207, 205b social environment in, 190–191
assignment despite objection and, change in, 103–112, 104f, 106f, 107t, staffing ratios in, 188, 188t
262 109f, 111t stress related to, 197–214. See also
decision-making in, 262–266 communication in, 74b, 74–82, 75t, Stress
documentation of practice situa- 76b–77b, 81t substance abuse in, 185–186
tion and, 262 cultural diversity in, 192–193 terrorism readiness and, 189–190
nursing care delivery and, 261 disaster readiness and, 189–190 unlicensed assistive personnel in,
resources for, 266 ergonomic injuries in, 184–185 188
Work climate ethics in, 48. See also Ethics violence in, 172, 176–179, 177b–179b
job choice and, 235 feedback in, 82t, 82–85, 83b–84b Worksheets
Work intensification health promotion in, 171–194 personalized patient, 119, 120f
conflict from, 93 impaired workers in, 185–186 in time management, 162
Working conditions latex allergy in, 181–183, 182t Written orders
codes of ethics and, 257–258 mandatory overtime in, 33–34, 187 physician, 81