Introduction to the Nursing Profession: Evolution, Theories, and Practice

The evolution of nursing is a dynamic journey that spans centuries, marked by transformative shifts in practice, education, and the professional identity of nurses. These shifts follow the historical progression of nursing and nursing theories, revealing the foundations that have shaped the field. Nursing education programs have likewise undergone significant development, adapting to the evolving healthcare landscape to equip nurses with the knowledge and skills necessary for contemporary practice.

As nursing emerged as a distinct profession, it became characterized by a commitment to compassionate care and a dedication to advancing the health and well-being of individuals and communities. Delving into the history and evolution of nursing theories introduces us to the visionary minds that have contributed to the theoretical frameworks supporting these core commitments. This journey includes an exploration of selected nursing theorists and the application of their theories in the dynamic and multifaceted realm of nursing practice, the application of nursing knowledge, skills, and principles. Together, these elements form a comprehensive picture that illustrates the rich and ever-evolving nature of nursing as a profession.

Evolution of Nursing and Nursing Practice

By the end of this section, you will be able to:

• Recognize the history of nursing and nursing practice
• Identify current trends in nursing
• Provide examples of the art and science of nursing practice

The profession of nursing encompasses the art and science of providing comprehensive care to promote and maintain health, prevent illness, and alleviate suffering for individuals, families, and communities. Nurses provide holistic care: for each patient, they consider the whole entity rather than focusing solely on individual parts.

In nursing practice, nursing knowledge, skills, and principles are applied in the delivery of health care to individuals, families, and communities. Nursing practice is rooted in a foundation of knowledge, clinical skills, and ethical principles, and it involves assessing health needs, developing care plans, administering treatments, and advocating for patients within the healthcare system. It extends across various settings, such as hospitals, clinics, homes, schools, and community environments, and involves collaboration with other healthcare professionals to ensure optimal outcomes for all receiving care. Central to the profession is a commitment to the well-being of individuals and communities, fostering a compassionate and person-centered approach to health care.

The history of nursing and nursing practice is a rich tapestry that countless practitioners and theorists have transformed over centuries. From informal caregiving in ancient civilizations to the highly skilled and respected profession it is today, nursing is marked by profound shifts in approach (D’Antonio et al., 2010). These historical perspectives serve as a testament to the resilience and adaptability of nurses in every setting and to their unwavering commitment to the well-being of individuals and communities worldwide.

Early Beginnings

The early beginnings of nursing can be traced back to ancient civilizations, where the care of the sick and injured was often a communal and familial responsibility. In these early societies, the role of a nurse was often fulfilled by family members, mainly women, who provided care within the home. Certain ancient cultures, such as Chinese and various American Indian, particularly valued individuals with specific knowledge of herbal remedies and healing practices. These individuals, often referred to as herbalists, played a role akin to what we now associate with nursing (Figure 1.2). Their knowledge of medicinal plants and holistic healing methods contributed to the well-being of their communities (D’Antonio et al., 2010).

Figure 1.2 Medicine women have been central figures in many cultures, including (a) indigenous women in Chile, (b) a Zulu shaman in Basutoland, and (c) the proprietor of a traditional Chinese medicine shop in Malaysia. (credit: (a) “Mapuche medicine woman treating a patient, South Chile” by Wellcome Images/Wikimedia Commons, CC BY 4.0; (b) “A Zulu medicine woman or shaman practicing in Basutoland, So” by Wellcome Images/Wikimedia Commons, CC BY 4.0; (c) “Medical Hall” by Oxlaey.com/Flickr, CC BY 2.0)

Throughout history, religious institutions have also played a significant role in caring for the sick. During the Middle Ages, when plagues and other illnesses were widespread, nursing duties in Western societies fell largely to religious orders. Monks and nuns provided care in monasteries and convents, demonstrating a commitment to service and compassion for the sick. The care provided during this period, however, was not formalized or regulated, and its quality varied widely (D’Antonio et al., 2010; Smith, 2023).

During the Renaissance period that began in Europe in the fourteenth century, a shift occurred in the perception of health care. The emergence of the scientific method and a greater understanding of anatomy and physiology began to influence medical practices. Despite these advancements, nursing remained an informal and often undervalued occupation for centuries. Yet these early beginnings of nursing, rooted in familial care and influenced by religious practices, set the stage for the professionalization and transformation of nursing into the vital and respected discipline it is today (D’Antonio et al., 2010).

Birth of Modern Nursing

The birth of modern nursing is credited to Florence Nightingale, a British nurse who played a transformative role in shaping the profession during the nineteenth century. Nightingale’s impact was particularly significant during the Crimean War (1853–1856), as she led a team of nurses to address the deplorable conditions in military hospitals. Nightingale’s emphasis on sanitation, hygiene, and compassionate care revolutionized hospital practices, fundamentally altering the landscape of health care and nursing. By implementing rigorous cleanliness measures, ensuring proper ventilation, and conducting statistical analysis of patient outcomes, she significantly reduced the spread of infectious diseases (Karimi & Masoudi Alavi, 2015; Smith, 2023).

The world’s first nursing school at St. Thomas’ Hospital was established in 1860 (Figure 1.3) which marked the formalization and professionalization of nursing education. The formal education of nurses, along with the establishment of professional standards and ethics, marked the transition from the informal caregiving of earlier centuries to the emergence of a dedicated and skilled nursing profession (D’Antonio et al., 2010).

Figure 1.3 This statue, outside St. Thomas’ Hospital, honors Mary Seacole, a Jamaican-born nurse who helped care for British soldiers during the Crimean War. (credit: “Mary Seacole statue, St. Thomas’ Hospital, front view,” by OwenBlacker/Wikimedia Commons, Public Domain)

Development of Nursing in the Nineteenth to Twenty-First Centuries

The development of nursing over the past 200 years represents a dynamic evolution marked by significant milestones, professionalization, and adaptation to the changing landscapes of health care. In the early twentieth century, an expansion of nursing practice took place, with nurses playing crucial roles in World Wars I and II and contributing to the establishment of nursing organizations like the American Nurses Association (ANA) in 1911 (D’Antonio et al., 2010).

In the mid-twentieth century, there were further advancements, including the development of specialized nursing fields and the creation of advanced practice roles. Witnessed in the latter part of the twentieth century were increasing diversity in the nursing workforce and a growing emphasis on evidence-based practice—trends that have continued through today. The profession has also adapted to technological innovations, such as electronic health record (EHR)s and telehealth, and embraced interdisciplinary collaboration (D’Antonio et al., 2010).

Throughout these centuries, nurses have faced challenges such as workforce shortages and increased demands on healthcare systems, leading to ongoing efforts to address these issues. The nursing profession has also experienced a shift toward greater autonomy and leadership roles for nurses, including the recognition of nurse practitioners as primary care providers (D’Antonio et al., 2010).

In recent decades, there has been a renewed focus on nursing education, research, and the global impact of nursing practice. Nurses have played pivotal roles in responding to public health crises, including the HIV epidemic, Ebola outbreaks, and the ongoing challenges posed by infectious diseases. In the twenty-first century, there is increased recognition of the importance of nursing in healthcare delivery (D’Antonio et al., 2010; Wakefield et al., 2021). Nurses contribute not only to direct patient care but also to health policy, research, and the development of innovative healthcare solutions. The COVID-19 pandemic further highlighted the indispensable role of nurses in providing frontline care and adapting to rapidly changing healthcare needs (Figure 1.4). Today’s nurses continue to be at the forefront of health care, contributing to improved patient outcomes and shaping the future of the profession.

Figure 1.4 Nurses, like these providers in a California hospital, helped lead the response to the COVID-19 pandemic in the United States. (credit: “USNS Mercy Medical Support at Skilled Nursing Facility Orange County,” by Navy Medicine/Flickr, Public Domain)

Real RN Stories

Navigating Cultural Sensitivity in the COVID-19 Pandemic

Nurse: Maria, BSN
Clinical setting: Pulmonary intensive care unit
Years in practice: 15
Facility location: Urban town in New Mexico

In the heart of the COVID-19 pandemic, I found myself at the frontline of a bustling urban hospital, facing the challenges of caring for patients from diverse cultural backgrounds. Our unit had transformed into a dedicated COVID-19 unit, and every day brought new hurdles, both physically and emotionally demanding. One particular day stands out, emphasizing the critical role of cultural competence in providing effective care. A patient from a close-knit immigrant community was admitted with severe COVID-19 symptoms. However, the family hesitated to follow some of the recommended treatments due to cultural beliefs and language barriers. Recognizing the need for cultural sensitivity, I took the initiative to connect with the patient’s family. With the assistance of a hospital interpreter fluent in their native language, we engaged in thoughtful conversations to understand their concerns and fears.

This challenging situation prompted collaboration with the hospital’s cultural competence team. Together, we developed a personalized care plan that respected the family’s cultural background, making adjustments to certain aspects of the treatment while ensuring essential medical interventions. Educational materials were provided in their native language to facilitate clear communication about the patient’s condition and the tailored care plan. Building trust with the patient’s family took time, but as we worked together, they began to see us as partners in their loved one’s care. The patient showed signs of improvement, and I continued to provide support, addressing their emotional needs during this challenging time.

This experience reinforced the significance of cultural competence in health care. It taught me and my colleagues the importance of understanding and respecting diverse perspectives, traditions, and beliefs. Embracing cultural competence enabled us to provide more effective and compassionate care, fostering trust and collaboration within the community we served. In reflecting on my experiences caring for COVID-19 patients and navigating cultural sensitivity, I couldn’t help but draw parallels to the timeless legacy of nursing pioneers like Florence Nightingale. Much like Nightingale, who revolutionized nursing during the Crimean War, the challenges posed by the pandemic prompted a transformation in our approach to patient care.

Nightingale emphasized the significance of holistic care, recognizing that it goes beyond merely treating the physical symptoms of an illness. As I encountered diverse patients from various cultural backgrounds, I realized that embracing cultural competence aligned with Nightingale’s principles of compassionate and patient-centered care. The tailored care plan we developed for the patient from the immigrant community reflected the ongoing evolution of nursing practices. Just as nursing pioneers adapted to the changing landscape of health care in their time, we, too, had to adapt and integrate cultural competence into our care strategies to meet the unique needs of our patients.

Current Trends in Nursing

Current trends in nursing reflect a dynamic landscape shaped by technological advancements, evolving healthcare needs, and recognition of the crucial role nurses play in patient care. Notable current trends in nursing include an ongoing nursing shortage, emphasis on higher education requirements, increase in online nursing education programs, expanded integration of telehealth and technology, and heightened focus on self-care for nurses (Wakefield et al., 2021). These trends collectively highlight the adaptability of nursing in response to contemporary challenges, positioning the profession to meet the diverse and evolving healthcare needs of society.

Continued Nursing Shortage

One prevailing trend in contemporary nursing is the continued shortage of nurses, a challenge that has persisted for several years, impacting the ability of healthcare systems to meet the growing demand for patient care. Several factors contribute to this shortage, including the expanding scope of healthcare services, an aging population with increased healthcare needs, and a similarly aging workforce that has seen many veteran nurses choosing to retire. Additionally, the limited number of qualified nursing instructors and available clinical sites impedes the possible growth of new nurses. The shortage is further exacerbated by factors such as inadequate nurse staffing ratios, high levels of burnout, and the demanding nature of the profession (Morris, 2023).

Efforts to address the nursing shortage include initiatives to attract individuals to the nursing profession, enhance educational opportunities, and create supportive work environments to retain experienced nurses. The ongoing shortage underscores the importance of strategic planning and collaborative efforts across healthcare stakeholders to ensure the sustainability and resilience of the nursing workforce in meeting the evolving healthcare needs of society.

Link to Learning

Higher Education Requirements

A notable trend in contemporary nursing is the increasing emphasis on higher education requirements for entry into the profession. While the traditional path of obtaining an associate degree in nursing (ADN) or a diploma in nursing remains common, there is a growing recognition of the benefits associated with a bachelor of science in nursing (BSN) as the minimum educational standard (Wakefield et al., 2021). This trend is influenced by a desire to elevate the overall quality of patient care, align nursing education with the complexities of modern health care, and enhance critical-thinking and leadership skills among nursing professionals. Many healthcare institutions and employers are now encouraging or requiring nurses to pursue BSN degrees, and some are advocating for a future in which the BSN becomes the standard entry-level qualification. This shift reflects a broader movement in health care toward fostering a highly educated and skilled nursing workforce capable of meeting the diverse and evolving needs of patients and the healthcare system.

Increase in Online Nursing Programs

Another notable trend in contemporary nursing education is the substantial increase in online nursing programs, reflecting the broader shift toward digital learning platforms. This trend has been accelerated by advancements in technology, the recognition of the need for flexible education options, and the impact of the COVID-19 pandemic. Online nursing programs offer accessibility and convenience, allowing aspiring nurses and working professionals to pursue their education without geographical constraints. These programs often integrate virtual simulations, interactive modules, and remote clinical experiences to provide a comprehensive and engaging learning experience. The surge in online nursing education is reshaping the traditional landscape of nursing programs, making education more accessible to a diverse student body and contributing to the ongoing evolution of nursing as a dynamic and technologically advanced profession.

Rise of Technology in Health Care

A significant contemporary trend in nursing is the accelerated adoption of telehealth, the use of digital communication technologies to deliver healthcare services and information remotely. The COVID-19 pandemic has expedited the integration of telehealth platforms, allowing nurses to provide patient care remotely through virtual consultations. This shift not only ensures continuity of care during unprecedented times but also aligns with the broader trend of incorporating technology into various aspects of health care.

Patient Conversations

Preparing a Patient for a Telehealth Visit

Nurse: Good morning. This is Nurse Sarai calling from Dr. Johnson’s office. Am I speaking with Mrs. Singh?

Patient: Yes, this is she. How can I help you?

Nurse: Hello, Mrs. Singh. Dr. Johnson has scheduled a telehealth visit with you today. Have you ever had a telehealth visit before?

Patient: No, it’s my first time. How does it work?

Nurse: You will be meeting with Dr. Johnson over a video call. It helps if you’re in a quiet room with good lighting. Do you have a smartphone, tablet, or computer with a camera?

Patient: Yes, I have a laptop.

Nurse: Perfect! Before the visit, make sure your laptop is charged and you have a stable internet connection. Also, test your camera and microphone to ensure they are working. Dr. Johnson will discuss your health, medications, and any concerns you might have, just like in a regular appointment.

Patient: Okay, that sounds pretty straightforward. Do I need to download any special software?

Nurse: No software is needed. We will send you a secure link via email and text just before the appointment time. All you have to do is click on the link, and it will take you to the virtual waiting room.

Patient: Okay, I will be looking for the link. Is there anything else I should be aware of?

Nurse: If you have a list of your current medications or any specific health concerns, it would be helpful to have that on hand.

Patient: Thank you for walking me through it, Nurse Sarai.

Nurse: You’re welcome, Mrs. Singh. If you have any questions or need assistance before or during the call, feel free to reach out. Dr. Johnson is looking forward to seeing you virtually today.

Patient: Thank you, Nurse Sarai. I appreciate your help.

Nurse: My pleasure! Take care, and we’ll talk to you soon.

Nurses are increasingly utilizing electronic health and medical records to streamline documentation, enhance communication among healthcare providers, and facilitate data-driven decision-making. An electronic health record (EHR) is a digital version of a patient’s medical history, maintained and shared by multiple providers. In contrast, only a single provider maintains and uses an electronic medical record (EMR). While both EHRs and EMRs serve as digital repositories for a patient’s medical information, they differ in terms of scope, accessibility, and functionality. The intent is for EMRs to feed into the EHR, providing a holistic approach to healthcare data, fostering coordination and collaboration among multiple entities involved in a patient’s care. The rise of wearable health technology and mobile health applications further empowers individuals to actively engage in their care, while nurses leverage these tools to monitor health metrics remotely.

Link to Learning

The video “I Am a Telehealth Nurse” features a pediatric nurse at Cincinnati Children’s Hospital who primarily uses digital tools to provide care.

The integration of telehealth and other forms of technology not only enhances healthcare accessibility but also transforms nursing practice, requiring nurses to adapt to evolving modes of patient interaction and data management. As technology continues to advance, nurses are at the forefront of harnessing its potential to optimize patient outcomes, promote preventive care, and contribute to the ongoing transformation of the healthcare landscape.

Essential Need for Nurses’ Self-Care

Another essential trend in contemporary nursing is the increasing recognition of the critical need for nurses’ self-care, intentional actions and practices that individuals engage in to promote their physical, mental, and emotional well-being. The demanding and often emotionally taxing nature of nursing, particularly exacerbated by the challenges posed by the COVID-19 pandemic, has underscored the importance of prioritizing nurses’ well-being. Healthcare institutions are placing a greater emphasis on creating supportive work environments, offering resources for mental health and resilience training, and implementing initiatives that address burnout. Nurses are encouraged to engage in self-care practices to mitigate stress, promote mental and physical health, and sustain their overall well-being. Acknowledging the essential role of nurses in the healthcare system, this trend reflects a broader understanding that fostering a culture of self-care is not only beneficial for individual nurses but is integral to sustaining a resilient and effective nursing workforce capable of delivering high-quality patient care (Morris, 2023).

Art and Science of Nursing

The art and science of nursing represent the dual nature of the nursing profession, encompassing both the humanistic and technical aspects of health care. The art of nursing emphasizes the interpersonal and compassionate dimensions of care. It involves the ability to connect with patients on a personal level, provide emotional support, and understand the unique needs and experiences of individuals under care. This aspect of nursing involves effective communication, empathy, and the cultivation of a therapeutic relationship between the nurse and the patient.

On the other hand, the science of nursing centers on the application of evidence-based knowledge, clinical skills, and technical expertise to deliver safe and effective patient care. It involves a thorough understanding of anatomy, physiology, pharmacology, and other scientific principles. Nurses use this scientific knowledge to assess, diagnose, plan, implement, and evaluate patient care, applying a systematic and analytical approach to clinical decision-making.

The integration of art and science is essential for holistic patient care. While the art of nursing ensures a human-centered and compassionate approach, the science of nursing provides the foundation for delivering evidence-based, quality health care. The synergy of these elements allows nurses to address the physical, emotional, and social dimensions of health, fostering a comprehensive and person-centered approach to nursing practice.

Soft Skills of Nursing

The soft skills in nursing are the interpersonal abilities and personal attributes that enhance a nurse’s ability to interact effectively with patients, families, and colleagues. Communication, empathy, cultural competence, collaboration and teamwork, adaptability, resilience, and problem-solving are examples of fundamental soft skills (Deering & Bal, 2023).

• Communication skills are paramount, encompassing the ability to listen attentively, convey information clearly, and show empathy.
• Empathy enables nurses to connect with patients on an emotional level, fostering trust and understanding.
• Cultural competence allows nurses to respect and navigate diverse backgrounds and beliefs, ensuring culturally sensitive care.
• Collaboration and teamwork are vital, as nurses often work within interdisciplinary teams, requiring effective communication and cooperation.
• Adaptability, resilience, and problem-solving skills are essential in the ever-evolving healthcare environment, enabling nurses to navigate challenges and overcome obstacles to providing person-centered care.

Ultimately, the cultivation of these soft skills enhances the holistic and compassionate nature of nursing practice, contributing to positive patient outcomes and a supportive healthcare environment.

Real RN Stories

Utilizing Soft Skills of Nursing

Nurse: Emily, BSN
Clinical setting: Emergency department
Years in practice: 8
Facility location: Rural town in North Dakota

One day, a distressed family arrived at the emergency department seeking updates about their older mother, who was admitted after a sudden cardiac event. The family was anxious, emotional, and struggling to comprehend the medical information. Recognizing the importance of effective communication and empathy, I took the time to sit down with the family in a private room. I actively listened to the family, allowing them to express their concerns and fears. I provided clear and compassionate explanations about the patient’s condition, the ongoing treatment plan, and what to expect in the coming days.

Understanding the family’s emotional state, I also offered comfort and reassurance, demonstrating empathy. I wanted to ensure the family felt heard and understood, addressing not only the medical aspects but also the emotional and psychological needs of the family. I felt like engaging in open and honest communication helped me to build trust with the family and foster a collaborative approach to care.

Throughout the patient’s stay, I continued to check in with the family, providing updates and maintaining a supportive presence. My ability to navigate these sensitive conversations, show empathy, and communicate effectively played a crucial role in easing the family’s anxiety and enhancing their overall experience during a challenging time. The family expressed gratitude for the personalized care and the sense of connection they felt and even gave me a hug before they were discharged home. This is just an example of how important it is for us nurses to be skilled in effectively using soft skills to provide holistic and person-centered care.

Hard Skills of Nursing

The hard skills in nursing encompass the technical and clinical competencies that are crucial for providing safe and effective patient care. These skills are typically acquired through formal education, training, and hands-on clinical experience. Clinical assessment and critical thinking are foundational hard skills, allowing nurses to analyze patient data, make accurate diagnoses, and develop appropriate care plans. Proficiency in administering medications, performing various medical procedures, and utilizing medical equipment are essential hard skills that ensure the delivery of precise and evidence-based care. Technical skills related to charting and documentation are crucial for maintaining accurate and comprehensive patient records. Advanced life support and emergency response skills are imperative for handling critical situations.

Throughout their career, nurses are expected to continuously update their hard skills to align with advancements in medical technology and evidence-based practices, ensuring they remain competent and capable in their clinical roles. In combination with soft skills, hard skills form a comprehensive skill set that equips nurses to deliver high-quality and proficient care across diverse healthcare settings.

Clinical Safety and Procedures (QSEN)

Mastery of Hard Skills in Nursing

The Quality and Safety Education for Nurses (QSEN) project stands as a cornerstone for the development and enhancement of hard nursing skills. The QSEN provides a structured framework for nurses to master essential competencies by focusing on the cultivation and application of evidence-based practice, technical proficiency, and rigorous clinical judgment.

The six core competencies within the QSEN framework highlight the importance of hard nursing skills. These competencies include patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics, all of which demand a solid foundation in hard skills for their effective implementation.

• Patient-centered care: The QSEN emphasizes the critical role of hard nursing skills in patient-centered care, urging nurses to master competencies such as effective health assessments, patient education techniques, and advocacy for patients’ rights and preferences. This core competency relies on a solid foundation of hard skills to ensure comprehensive and personalized patient care.
• Teamwork and collaboration: Within the QSEN framework, teamwork and collaboration necessitate hard nursing skills such as interprofessional communication, collaborative care planning, effective delegation, conflict resolution, and shared decision-making. Nurses are encouraged to cultivate these technical abilities to foster cohesive teamwork and enhance the overall quality of patient care.
• Clinical excellence: The QSEN underscores the significance of hard skills in achieving clinical excellence. Proficiency in medical procedures, accurate clinical judgment, and adherence to evidence-based practices are central components. The initiative serves as a guide for nurses to sharpen their technical skills and ensure a high standard of care.
• Evidence-based practice: As an advocate for evidence-based practice, QSEN places a premium on the integration of the latest research and clinical evidence into nursing care. This emphasis reinforces the importance of hard skills in critically assessing and applying scientific knowledge to inform decision-making.
• Continuous quality improvement: The QSEN encourages a commitment to continuous quality improvement, aligning closely with the development of hard nursing skills. Nurses are prompted to refine their technical abilities, embrace innovations in health care, and actively contribute to elevating the overall quality of patient care.
• Patient safety: Focused on patient safety, QSEN highlights hard skills as the foundation for creating a secure healthcare environment. Proficiency in medical procedures, precise clinical assessments, and a vigilant approach to safety protocols are vital components in ensuring patient well-being.

Nursing Education Programs

By the end of this section, you will be able to:

• Compare and contrast levels of nursing education
• Describe the licensure process for nursing practice

Navigating the landscape of nursing education involves exploring the available levels of education, each of which contributes uniquely to the development of nursing professionals. Aspiring nurses encounter distinct educational pathways, ranging from practical and vocational nursing programs to more advanced degrees like associate, bachelor, and graduate levels. Each tier not only shapes the depth of clinical knowledge but also influences critical-thinking skills and leadership capabilities. Alongside the diverse educational avenues, the licensure process stands as a pivotal gateway for nursing practice. This process, governed by regulatory bodies, establishes a standardized framework to ensure that nurses meet essential qualifications and competencies. Understanding the licensure journey is crucial for aspiring nurses, as it encompasses examinations, practical assessments, and adherence to ethical standards that are prerequisites to a rewarding and impactful career in health care.

Nursing education encompasses a range of programs designed to prepare individuals for diverse roles within the healthcare profession. Entry-level pathways into the nursing profession include licensed practical nurse (LPN)/licensed vocational nurse (LVN), ADN, and BSN programs, each offering a tiered progression of education and skills development for individuals aspiring to become nurses. Graduate-level nursing programs—such as Master of Science in Nursing (MSN), doctor of nursing practice (DNP), and Doctor of Philosophy (PhD) in Nursing—are designed to provide advanced education and specialized training for registered nurses seeking to enhance their clinical expertise and leadership skills and engage in research to contribute to the advancement of nursing practice and knowledge. These diverse educational pathways cater to individuals with varying career aspirations, contributing to a well-rounded and skilled nursing workforce capable of meeting the evolving demands of the healthcare landscape.

Licensed Practical Nurse/Licensed Vocational Nurse

The positions of licensed practical nurse (LPN) and licensed vocational nurse (LVN) are fundamentally equivalent; the particular term depends on the state in which the nurse is licensed, but all LPNs and LVNs have completed a specialized nursing education program that equips them with the skills and knowledge required for entry-level positions in health care. Typically offered by vocational schools, community colleges, or technical institutes, these programs span 12 to 18 months, with a curriculum focused on practical nursing skills and basic nursing education (A guide to the different types of nursing degrees, n.d., Ko, 2023; Mills, 2023; Types of nursing degrees and levels, 2023).

Following program completion, graduates must pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN) to obtain licensure. The LPNs/LVNs work under the supervision of registered nurses or providers, providing basic nursing care such as administering medication, treating wounds, monitoring vital signs, and assisting with activities of daily living. The LPNs/LVNs contribute to overall patient care but may have limited involvement in complex decision-making or creation of the patient care plan (A guide to the different types of nursing degrees, n.d.; Ko, 2023; Mills, 2023; Types of nursing degrees and levels, 2023). Their scope of practice varies by state and includes roles in hospitals, long-term care facilities, physician’s offices, and community clinics. The LPNs/LVNs may choose to advance their career by pursuing further education, such as becoming a registered nurse (RN) through an LPN-to-RN bridge program.

Associate Degree in Nursing

The associate degree in nursing (ADN) is a two-year program offered by various educational institutions, including community colleges and technical schools, designed to prepare individuals for a career as a registered nurse (RN). The ADN curriculum encompasses a blend of general education courses and nursing-specific content, providing a broader and more comprehensive foundation than does the LPN/LVN curriculum (A guide to the different types of nursing degrees, n.d.; Ko, 2023; Mills, 2023; Types of nursing degrees and levels, 2023).

Upon program completion, graduates are eligible to take the National Council Licensure Examination for Registered Nurses (NCLEX-RN), a prerequisite for obtaining licensure as a registered nurse. The RNs have a broader scope of practice than LPNs/LVNs. In addition to assessing patients and administering medication, they are involved in planning care. The ADN-prepared nurses are trained to make independent clinical decisions and collaborate with other healthcare professionals in complex patient situations (A guide to the different types of nursing degrees, n.d.; Ko, 2023; Mills, 2023; Types of nursing degrees and levels, 2023). Consequently, they often have more immediate opportunities for career advancement, and they can pursue additional education, such as a BSN degree, to open up further career prospects.

Bachelor of Science in Nursing

A bachelor of science in nursing (BSN) is a comprehensive degree program designed to prepare an individual for a career as an RN; the robust educational requirements typically take four years to complete, though some accelerated programs can be completed in a shorter time frame. Compared to the ADN program, the BSN program offers a broader education, including a more extensive range of general education courses. It covers not only clinical skills but also theory, research, leadership, and public health. Emphasizing critical thinking and evidence-based practice, BSN programs equip nurses with a holistic understanding of health care. The BSN-prepared nurses have an expanded scope of practice, engaging in more complex patient care, decision-making, and coordination of care. The BSN curriculum also includes components on leadership and management, preparing nurses for supervisory roles and leadership within healthcare teams (A guide to the different types of nursing degrees, n.d.; Mills, 2023; Types of nursing degrees and levels, 2023).

Graduates of BSN programs are eligible to take the NCLEX-RN, which is a prerequisite for obtaining licensure as an RN. The BSN-prepared nurses are positioned for career advancement, with increased opportunities in management, education, research, and specialized nursing roles. The emphasis on professional development encourages ongoing education, certifications, and advanced degrees, reflecting the evolving standards in the nursing profession.

Master’s Degree in Nursing

A Master of Science in Nursing (MSN) is an advanced graduate degree that provides nurses with a higher level of education and specialization in various areas of nursing practice. Typically pursued after obtaining a BSN degree, an MSN degree is designed to equip nurses with advanced knowledge, skills, leadership, and critical-thinking abilities. The curriculum of an MSN program varies based on the chosen specialty track, which may include options such as nurse practitioner, nurse educator, nurse administrator, or clinical nurse specialist. The program often integrates advanced coursework in areas such as nursing theory, research methods, health policy, and leadership. Clinical experiences and practicums are common components, allowing students to apply advanced theoretical concepts in real-world healthcare settings (A guide to the different types of nursing degrees, n.d.; Types of nursing degrees and levels, 2023).

Graduates of MSN programs are prepared for advanced practice roles, leadership positions, and specialized nursing functions. The MSN degree serves as a pathway for nurses seeking career advancement, increased autonomy, and the ability to contribute to shaping healthcare policies and practices. Additionally, the MSN is often a prerequisite for pursuing doctoral-level education in nursing, such as a DNP or a PhD in nursing. The pursuit of an MSN reflects a commitment to ongoing professional development and a desire to play a pivotal role in addressing the evolving challenges and complexities within the healthcare system (A guide to the different types of nursing degrees, n.d.; Types of nursing degrees and levels, 2023).

Doctoral Degrees in Nursing

Doctoral degrees in nursing education are terminal degrees, representing the highest level of academic achievement in the nursing profession. Doctoral degrees provide nurses with advanced knowledge, leadership skills, and expertise in specialized areas. Two primary doctoral degrees in nursing education are the Doctor of Nursing Practice (DNP) and the Doctor of Philosophy (PhD) in Nursing degrees. The DNP is a practice-focused doctoral degree that emphasizes advanced clinical practice, leadership in healthcare systems, and evidence-based decision-making. The DNP-prepared nurses are equipped to lead and innovate in clinical settings, shaping healthcare policy and practice. The PhD in nursing is a research-focused doctoral degree that emphasizes the generation of new knowledge through rigorous scientific inquiry (Bal, 2023; Types of nursing degrees and levels, 2023). The PhD-prepared nurses contribute to the development of nursing science through research, scholarly publications, and academic teaching. Pursuing a doctoral degree in nursing education reflects a commitment to advancing the nursing profession, contributing to evidence-based practice, and shaping the future of health care through leadership, research, and education.

American Association of Colleges of Nursing Essentials of Associate Education for Professional Nursing Practice

The American Association of Colleges of Nursing (AACN) is a professional organization that represents schools of nursing in the United States. Founded in 1969, the AACN is dedicated to advancing nursing education, research, and practice. It serves as a national voice for nursing education, influencing policy, promoting quality standards in nursing education, and advocating for the nursing profession (AACN, 2021).

The AACN Essentials of nursing education delineate the core principles and competencies for various levels of nursing education. Each set of AACN Essentials, whether for associate, baccalaureate, master, or doctoral education, serves as a framework to guide the development of nursing programs and ensure the preparation of competent and professional nurses. Collectively, they define the standards and expectations for nursing education in the United States, ensuring a continuum of excellence in nursing practice across various roles and responsibilities (AACN, 2021).

The current AACN Essentials, introduced in April 2021, are structured around ten domains (AACN, 2021):

1. Knowledge for Nursing Practice
2. Person-Centered Care
3. Population Health
4. Scholarship for Nursing Practice
5. Quality and Safety
6. Interprofessional Partnerships
7. Systems-Based Practice
8. Informatics and Healthcare Technologies
9. Professionalism
10. Personal, Professional, and Leadership Development

Each domain includes level 1 and level 2 subcompetencies, tailored to differentiate between entry-level and advanced-level nursing education. Eight professional nursing practice concepts, such as clinical judgment, communication, compassionate care, social determinant of health, and ethics, are emphasized. The Essentials are intentionally designed using a competency-based education model to bridge the gap between education and practice; they are intended to be applicable across different educational stages and adaptable to various curricular models. The ultimate goal is to ensure graduates of nursing programs demonstrate competency in relevant areas, aligning with the evolving needs of health care and improving overall learning outcomes (AACN, 2021).

Link to Learning

The AACN’s The Essentials 2021 outlines curriculum requirements and expected competencies for each level of nursing education.

Licensure

Nursing licensure is a critical regulatory process that ensures individuals practicing nursing meet established standards of competency and adhere to ethical and legal guidelines. Licensure is typically granted by the state’s nursing regulatory board, or a similar governing body, and signifies that an individual has successfully completed the required education and training to practice as a nurse. The process involves passing a standardized examination, most commonly the NCLEX-RN for RNs or the NCLEX-PN for LPNs/LVNs (National Council of State Boards of Nursing, 2023).

Licensure for advanced practice registered nurse (RN), such as nurse practitioners, nurse anesthetists, nurse-midwives, and clinical nurse specialists, is a specialized regulatory process that acknowledges the advanced education, training, and clinical expertise of these professionals. The licensure process for APRNs typically involves obtaining an advanced practice nursing license in addition to, or as part of, the RN license. Key components of advanced practice licensure often include completing a master’s or doctoral degree in nursing, obtaining national certification in the respective advanced practice specialty, and fulfilling clinical practice hours. National certification is usually granted by specialty nursing organizations or certification boards and is often a prerequisite for state-level advanced practice licensure (National Council of State Boards of Nursing, 2023).

In addition to examination requirements, licensure for RNs and APRNs may involve meeting specific educational criteria, accruing clinical experience hours, and adhering to professional and ethical standards. Nursing licensure not only validates a nurse’s competence but also provides a legal framework for accountability and protection of the public. Licensure requirements vary by jurisdiction, and maintaining an active license often requires ongoing professional development through continuing education (CE) to ensure nurses stay current with advancements in healthcare practices and technologies (National Council of State Boards of Nursing, 2023). The licensure process plays a crucial role in upholding the quality and safety of patient care while regulating the nursing profession to meet the evolving needs of healthcare delivery.

Continuing Education

Ongoing educational activities known as continuing education (CE) are a vital component of nursing practice. The CE activities include workshops, seminars, conferences, online courses, and formal academic programs on a broad spectrum of topics, such as new treatment modalities, advances in technology, changes in healthcare laws and regulations, cultural competency, and patient safety measures. The purpose of CE is multifaceted. It ensures nurses remain competent and knowledgeable in their practice and stay current with evolving medical knowledge, technological advancements, and best practices in patient care. Additionally, CE fosters professional growth and development and helps nurses adapt to the dynamic landscape of health care, integrating evidence-based practices into their clinical care.

Compliance with CE requirements is often a condition for license renewal. The specific requirements vary by jurisdiction, and each state’s nursing board establishes guidelines for CE that nurses must follow. This commitment to lifelong learning not only benefits individual practitioners, it also maintains high standards of patient care and safety throughout healthcare systems, enhancing their overall quality.

Career Development and Specialty Certification

Career development and specialty certification play crucial roles in advancing nursing practice, providing opportunities for professional growth and enhancing the quality of patient care. In nursing, career development encompasses a broad spectrum of activities aimed at advancing a nurse’s professional trajectory. This may include pursuing advanced degrees (such as a master’s or doctoral degree), assuming leadership roles, engaging in research, or transitioning into educational roles. Career development activities are often driven by a nurse’s individual goals, interests, and aspirations for their professional journey.

As nurses progress in their careers, pursuing a specialty certification becomes a valuable means of demonstrating expertise and dedication to a particular area of nursing. While licensure grants the legal authority to practice as a nurse, specialty certifications offer a way for nurses to showcase advanced knowledge and skills within a specific niche. Specialty certification involves meeting established criteria: often a combination of education, clinical experience, and successful completion of a certification exam. Certifications are available in various specialties, such as critical care, pediatric nursing, oncology, and nurse anesthesia, among others. These certifications not only validate a nurse’s proficiency in a specialized area but also contribute to their overall career development.

Both career development and specialty certification contribute to the continuous improvement of patient care. Nurses who actively engage in career development contribute to the overall advancement of the nursing profession, taking on leadership positions, participating in research initiatives, and shaping healthcare policies. Nurses with specialized certifications bring enhanced knowledge and skills to their roles, resulting in improved patient outcomes. While licensure provides the foundation for nursing practice, career development and specialty certification serve as dynamic elements that empower nurses to excel in their chosen areas, contribute to the advancement of health care, and shape the future of nursing.

Real RN Stories

Career Development through National Certification

Nurse: Lindsay, BSN
Clinical setting: Medical-surgical department
Years in practice: 13
Facility location: Suburban area in North Carolina

Early in my nursing career, I knew that I wanted to obtain a national certification in my specialty area of medical-surgical nursing. After establishing a robust practical foundation as a medical-surgical nurse, I started to research what additional steps I would need to take. After confirming that I had met the practice requirements of two years full-time as an RN and had completed the required thirty CE credits, I began studying and registered to take the certification exam.

I became certified in medical-surgical nursing during my third year as a nurse and have maintained it ever since. This certification became a transformative milestone, allowing me to deepen my expertise in medical-surgical nursing. It equipped me with the latest evidence-based practices, significantly enhancing the quality of care for a diverse range of medical-surgical patients in the fast-paced environment of the hospital. Not only did my journey to certification help my own practice, but it also became a source of inspiration for my nursing colleagues. I actively engaged in mentorship, encouraging fellow medical-surgical nurses to explore the unique opportunities that certification brings to our specialty. A year or two after I became certified, four of my colleagues became certified as well, which furthered the expertise and care our department could provide to our patients.

In-Service Education

Many healthcare institutions offer licensed nurses opportunities for ongoing training, known as in-service education. Often these programs address the evolving nature of health care, licensure renewal prerequisites, or other specific needs of the nursing staff. They cover a spectrum of topics, including clinical updates, patient safety measures, quality improvement, and regulatory compliance. By providing opportunities for ongoing learning and skill enhancement, in-service education not only helps nurses stay current with best practices but also ensures they adhere to ethical standards, legal obligations, and regulatory requirements, ultimately promoting optimal patient care and safety.

Clinical Safety and Procedures (QSEN)

In-Service Education for Clinical Safety

In-service education programs play a pivotal role in ensuring clinical safety and adherence to best practices in health care. Addressing the core principles of QSEN, these initiatives aim to enhance the competence and skills of healthcare professionals in delivering safe and effective patient care.

• Focus on QSEN principles: In-service education programs aligned with QSEN principles prioritize areas such as patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. By integrating these principles into ongoing training, healthcare institutions foster a culture of continuous learning and improvement.
• Clinical updates and best practices: In-service education initiatives in clinical safety and procedures provide healthcare professionals with essential updates on clinical protocols, safety measures, and evidence-based procedures. This ensures that nurses stay abreast of the latest advancements, contributing to enhanced patient safety.
• Ethical standards and regulatory compliance: Beyond clinical skills, in-service education emphasizes ethical standards, legal obligations, and regulatory requirements. By promoting adherence to these principles, these programs contribute to maintaining the highest standards of professional conduct and safeguarding patient well-being.
• Optimizing patient care: In-service education in clinical safety and procedures is not only a requirement for professional growth but also a commitment to optimizing patient care. The continuous enhancement of skills and knowledge empowers healthcare professionals to deliver high-quality, safe, and patient-centered care in evolving clinical environments.

As an integral part of healthcare education, in-service programs aligned with QSEN principles demonstrate the industry’s dedication to maintaining excellence in clinical safety and procedures. These initiatives support healthcare professionals in upholding the highest standards of care and contribute to the ongoing improvement of patient outcomes.

Professional Nursing Organizations

A professional nursing organization is a collective body formed by nurses to represent and advocate for the interests of the nursing profession. Professional nursing organizations share a symbiotic relationship with licensing bodies. Organizations such as the ANA, National Council of State Boards of Nursing, and various specialty-specific groups play a vital role in shaping the standards and guidelines for nursing licensure. They actively engage in advocacy efforts, influencing legislative decisions and policies to ensure that licensure processes are fair, transparent, and reflective of the current healthcare landscape.

Professional nursing organizations also collaborate with regulatory bodies to establish educational requirements, competency assessments, and CE expectations, contributing to the continuous professional development of nurses. Through networking opportunities and collaborative initiatives, these organizations provide a platform for nurses to collectively address challenges, share best practices, and contribute to the ongoing improvement of licensure standards. Additionally, professional nursing organizations emphasize the importance of ethical standards, research, and evidence-based practice, influencing the ethical considerations and scientific foundations embedded in the licensure process. The collaboration between professional nursing organizations and licensure ensures that nursing standards evolve to meet the dynamic needs of health care, uphold ethical principles, and foster the highest quality of patient care.

Nursing as a Profession

By the end of this section, you will be able to:

• Describe the scope of practice for the nursing profession
• Explain standards of practice for the nursing profession
• Discuss nursing roles and responsibilities within the profession

Within the realm of health care, nursing stands as a dynamic and essential profession marked by a holistic commitment to patient care and well-being. The scope of practice for nurses encompasses a wide spectrum of responsibilities, ranging from direct patient care to collaboration with interdisciplinary teams. As professionals dedicated to promoting health and preventing illness, nurses play pivotal roles in various healthcare settings. The nursing profession adheres to rigorous standards of practice, ensuring that practitioners maintain the highest level of competence and ethical conduct. These standards guide nurses in delivering safe, effective, and person-centered care. Within this professional landscape, nurses experience diverse roles and responsibilities, encompassing caregiver, decision-maker, collaborator, communicator, advocate, and educator. This section explores the multifaceted nature of nursing as a profession, delving into its scope and standards and the critical roles and responsibilities that define and elevate the practice of nursing in the complex and ever-evolving healthcare environment.

Scope of Practice

The scope of practice refers to the defined limits and parameters within which a professional is authorized to work, make decisions, and provide services. It is a set of regulations, guidelines, and standards that delineate the range of duties, responsibilities, and activities that individuals within a specific profession are educated, trained, and legally permitted to perform. The scope of practice is established by regulatory bodies, licensing boards, and professional organizations to ensure that professionals operate within their competencies, uphold ethical standards, and provide safe and effective care (ANA, n.d.b).

The scope of nursing practice encompasses the range of roles, responsibilities, activities, and interventions that a RN or LPN/LVN is educated, trained, and authorized to perform within the legal and ethical boundaries of their licensure. The scope of practice is defined by regulatory bodies, such as state Boards of Nursing in the United States, and informed by national and international professional organizations like the ANA and the International Council of Nurses (ICN). The specific scope of practice for a nurse is influenced by factors such as education, experience, and additional certifications or specialties. It is important to note that the specific details of the scope of practice can vary by jurisdiction (ANA, n.d.b). Nurses must know the regulations and guidelines set by their state’s or country’s regulatory authority and engage in regular updates and ongoing education to stay current with evolving healthcare practices and maintain competence within the defined scope of nursing practice.

Real RN Stories

Knowing Scope of Practice Boundaries

Nurse: Julian, BSN
Clinical setting: Urgent care
Years in practice: 28
Facility location: Suburban city in Alabama

As a nurse, it is important to know your scope of practice to ensure you stay within your practice guidelines. There is one situation in particular that stands out for testing the boundaries of my scope of practice. One day, my charge nurse approached me with a request to administer a medication to a patient before the provider had written the order for the medication.

Recognizing the potential risks and ethical considerations involved in the situation, I hesitated and expressed my concerns about administering medication without an order. The charge nurse explained the provider was attending to an emergency and would be delayed in providing the order. Despite the urgency conveyed by the charge nurse, I emphasized the importance of obtaining a proper order to ensure the patient’s safety and well-being.

This experience took an even more critical turn when it was later discovered that the patient had a known allergy to the medication in question. Had I proceeded without an order, it could have led to severe consequences for the patient. This just reinforced the importance of adhering to established protocols and emphasized the potential risks associated with deviating from them.

This experience highlighted the importance of advocating for patient safety, even in challenging circumstances. It also underscored the significance of effective communication within the healthcare team and the commitment to upholding professional standards, ensuring that patient care aligns with established protocols and maintains the highest standards of safety and professionalism.

International Council of Nurses

The International Council of Nurses (ICN) holds a pivotal role in shaping and advancing the global nursing profession, providing essential guidance on the scope of practice for nurses. As a worldwide federation of national nursing associations, the ICN serves as a unifying force, representing millions of nurses with a shared mission to elevate the nursing profession and contribute to improved global health (ICN, n.d.).

Recognizing the inherent diversity in nursing practices across countries and regions, the ICN establishes overarching principles and guidelines that underscore the foundational elements of nursing practice. Central to its framework is the acknowledgment of nurses as autonomous professionals, empowered to make independent judgments and decisions within their designated scope of practice. This emphasis on autonomy is complemented by a commitment to accountability, ensuring that nurses are responsible for the outcomes of their practice (ICN, n.d.).

Collaboration is another cornerstone of the ICN’s vision for nursing. The framework underscores the importance of nurses working in close partnership with other healthcare professionals, fostering a collaborative approach to deliver comprehensive and well-coordinated care to individuals and communities. Advocacy features prominently in the ICN’s guidance, emphasizing the vital role of nurses as advocates for patients (ICN, n.d.). Nurses are entrusted with the responsibility to ensure that the needs, preferences, and rights of patients are not only acknowledged but also respected within the broader healthcare system.

Education and professional development are encouraged by the ICN, recognizing the dynamic nature of health care and the need for nurses to continually enhance their knowledge and skills. This commitment to ongoing learning is vital for staying abreast of evidence-based practices and ensuring the delivery of high-quality care. Ethical practice is another core tenet outlined by the ICN, emphasizing the importance of nurses upholding stringent ethical standards. This includes safeguarding patient confidentiality, respecting cultural diversity, and promoting the well-being and dignity of those under their care (ICN, n.d.).

The ICN’s guidance serves as a global compass for nursing, fostering consistency, excellence, and a shared commitment to advancing health care on an international scale. Crucially, the ICN acknowledges that the scope of nursing practice is context dependent, varying based on local regulations, laws, and educational standards (ICN, n.d.). The organization provides a flexible framework that countries and regions can adapt to their specific needs, allowing for a nuanced approach to nursing practice that aligns with local requirements and priorities.

American Nurses Association

The American Nurses Association (ANA) is a national professional nursing organization formed by nurses to represent and advocate for the interests of the nursing profession. It is one of the largest and most influential such organizations in the United States, advocating for the interests of nurses and the nursing profession. The ANA works to advance the profession of nursing by promoting high standards of nursing practice, providing guidance on ethical issues, and influencing healthcare policy (ANA, n.d.a).

The ANA plays a central role in shaping and defining the scope of practice for nurses in the United States. As the premier professional organization representing the interests of RNs, the ANA provides leadership, guidance, and advocacy to ensure the highest standards of nursing practice. The ANA recognizes the dynamic and evolving nature of health care and nursing, and as such, it continually updates and revises its Scope and Standards of Practice to reflect contemporary healthcare needs and professional advancements (ANA, n.d.a).

Through publications such as the Scope and Standards of Practice, the ANA delineates the competencies, responsibilities, and ethical considerations that define the scope of nursing practice. This document serves as a comprehensive guide for nurses, educators, policymakers, and the public, outlining expectations for the delivery of safe, quality, and person-centered care (ANA, n.d.b). The ANA’s influence extends beyond individual practice, contributing to the development of policies and regulations that govern nursing practice at local, state, and national levels, thereby shaping the landscape of healthcare delivery in the United States.

State Boards of Nursing

A board of nursing (BON), typically established at the state or territorial level, is a regulatory body tasked with overseeing the practice of nursing within its jurisdiction. One of the primary responsibilities of a BON is defining and regulating the scope of practice for nurses. The board sets guidelines and standards that govern the legal and ethical boundaries within which nurses can provide care. These guidelines outline the permissible activities, responsibilities, and competencies for different levels of nursing professionals, ensuring safe and effective patient care. The BONs collaborate with professional nursing organizations, educators, and other stakeholders to regularly review and update these standards to reflect advances in health care, changes in legislation, and evolving societal needs. Additionally, BONs are responsible for licensing nurses, establishing educational requirements, and enforcing regulations to uphold the integrity of the nursing profession.

Licensing is a state-specific process overseen by state BONs, ensuring nurses meet the qualifications and standards set by the respective state for safe and competent practice. The Nurse Licensure Compact is an agreement among participating states that allows nurses to hold one multistate license, granting them the privilege to practice in other compact states without obtaining additional licenses. This compact enhances mobility for nurses and facilitates access to healthcare services across state borders, while still maintaining regulatory standards and patient protection. Through these mechanisms, BONs play a crucial role in safeguarding public health while providing a framework that allows nurses to practice within well-defined parameters.

Standards of Practice

The Standards of Practice are comprehensive guidelines that articulate the expectations and ethical conduct required of nurses in their professional roles. These standards serve as a foundational framework, ensuring uniformity, quality, and safety in patient care. While specific criteria may vary across regions, many standards align with overarching principles advocated by professional nursing organizations.

Fundamental aspects found in these standards include the promotion of professionalism, integrity, and accountability among nurses. The emphasis on person-centered care underscores the importance of respecting individual values, preferences, and autonomy. Safety and quality considerations prioritize a culture of continuous improvement and a sanitary and secure healthcare environment. Effective communication and collaboration with patients and healthcare colleagues are highlighted, promoting interdisciplinary teamwork. The integration of evidence-based practice encourages nurses to utilize the best available evidence in conjunction with clinical expertise to inform decision-making.

Commitment to ongoing education and professional development is emphasized, ensuring nurses stay abreast of evolving healthcare practices. Ethical conduct, legal compliance, and cultural competence are integral components of these standards, ensuring nurses uphold ethical principles, adhere to legal regulations, and provide culturally sensitive and equitable care. Adherence to standards of practice is crucial for upholding the integrity of the nursing profession and delivering safe, ethical, and high-quality patient care.

Code of Ethics

An ethical principle is a fundamental concept that guides individuals and professionals in determining what is right or wrong in a given situation. Ethical principles provide a framework for appropriate decision-making and behavior, helping to ensure that actions align with moral values and standards. Within nursing, these ethical principles are collated into the nursing code of ethics, a comprehensive set of principles that defines the ethical responsibilities and standards expected of nurses in their professional practice (ANA, 2015; Gaines, 2023).

The nursing code of ethics, as articulated by organizations like the ANA, is based on five main ethical principles: nonmaleficence, beneficence, autonomy, justice, and confidentiality (Table 1.1).

Table 1.1 Ethical Principles for Nurses

In adhering to this code, nurses commit to upholding the highest standards of ethical practice, ensuring the well-being and safety of patients. The code encompasses a set of principles that underscore the essential values and obligations of nursing professionals. Central to the nursing code of ethics is the principle of patient-centered care. Nurses prioritize the needs and preferences of patients, recognizing and respecting their autonomy, individuality, and right to make informed decisions about their health care. This commitment extends to fostering open communication, building trust, and maintaining confidentiality to uphold the privacy of patients. Another fundamental principle is the obligation to provide competent and safe care. Nurses continually strive to enhance their knowledge and skills, staying abreast of advancements in health care to deliver evidence-based and quality care (ANA, 2015; Gaines, 2023). This includes advocating for a supportive work environment that facilitates ongoing education and professional growth.

The nursing code of ethics underscores the importance of maintaining integrity and honesty in all professional interactions. Nurses are expected to uphold the trust placed in them by the public and colleagues, fostering a culture of transparency and accountability. This involves addressing any conflicts of interest and ensuring that decisions are guided by ethical considerations rather than personal gain. Collaboration and advocacy are integral components of the nursing code of ethics. Nurses work collaboratively with interdisciplinary teams to optimize patient outcomes, promoting a holistic approach to health care. Additionally, they serve as advocates for patients, ensuring that their rights are upheld and that they receive equitable and compassionate care. Finally, the nursing code of ethics emphasizes the responsibility of nurses to contribute to the advancement of the profession (ANA, 2015; Gaines, 2023). This involves engaging in scholarly activities, participating in professional organizations, and actively contributing to the ongoing development of nursing knowledge and practice.

Quality and Safety Education for Nurses

The Quality and Safety Education for Nurses (QSEN) initiative serves as a framework for nursing education and practice, emphasizing the integration of quality and safety principles into nursing education and clinical care. While QSEN itself is not a set of formal nursing standards of practice like those established by regulatory bodies or professional organizations, it has influenced nursing education and practice standards by promoting key competencies essential for delivering safe and high-quality patient care (QSEN Institute, n.d.).

The QSEN identifies six core competencies that align with nursing standards and guide nursing education:

1. Patient-centered care focuses on the individual needs, preferences, and values of patients. This competency aligns with nursing standards that emphasize a person-centered approach, recognizing the importance of involving patients in their care and decision-making.
2. Teamwork and collaboration together promote effective communication and cooperation among healthcare team members, aligning with standards that highlight the significance of interdisciplinary teamwork and communication to enhance patient outcomes.
3. Evidence-based practice (EBP) integrates the best available evidence with clinical expertise and patient values to guide nursing practice. Evidence-based practice is a foundational standard in nursing, emphasizing the importance of using the latest evidence to inform decision-making.
4. Quality improvement involves continuous efforts to enhance patient care and outcomes, which aligns with nursing standards that advocate for ongoing quality assessment and improvement within healthcare organizations.
5. Safety prioritizes the safety of both patients and healthcare providers. It is a core principle in nursing practice standards, and the existence of QSEN reinforces the importance of creating a culture of safety within healthcare settings.
6. Informatics promotes the use of information and technology to support and improve healthcare delivery, which aligns with nursing standards that recognize the role of these tools in enhancing patient care and communication.

Nursing Roles and Responsibilities

Nursing roles and responsibilities encompass a diverse array of critical functions within the healthcare system. At its core, nursing involves being a compassionate caregiver, providing holistic and person-centered care that addresses physical, emotional, and psychological needs. Nurses act as decision-makers, exercising clinical judgment, prioritizing care, and contributing to ethical discussions. In the role of a manager of care, nurses coordinate and optimize healthcare services, overseeing interdisciplinary teams and navigating complex healthcare systems. As communicators, nurses bridge the gap between patients, their families, and the healthcare team, facilitating effective information exchange and fostering therapeutic relationships. Nurses also serve as advocates, ensuring that patients’ voices are heard, their rights are respected, and their choices are considered in decision-making processes. Additionally, nurses act as educators, imparting essential knowledge to patients and communities, promoting health literacy, and empowering individuals to actively participate in their well-being.

Real RN Stories

Navigating Nursing Roles and Responsibilities

Nurse: Thara, BSN
Clinical setting: Intensive care unit (ICU)
Years in practice: 10
Facility location: Urban hospital in New York

Working in the ICU of a bustling urban hospital, my daily responsibilities extend beyond the traditional image of a nurse. In the ICU, I play a pivotal role in patient advocacy, acting as a liaison between patients, their families, and the interdisciplinary healthcare team. As a patient advocate, effective communication is critical, not only in delivering medical information but also in offering emotional support during challenging times. The ICU environment demands sharp critical thinking and quick decision-making. I face dynamic situations that require immediate intervention and adaptability. Whether it’s responding to sudden changes in a patient’s condition or collaborating with physicians on treatment plans, my ability to think on my feet is a constant asset.

As an experienced ICU nurse, I often find myself in leadership roles during emergencies. I lead resuscitation efforts, coordinate the response to critical events, and ensure seamless communication among the healthcare team. My leadership extends to mentoring newer nurses, fostering a culture of continuous learning and collaboration. I also provide leadership and expertise across the hospital as the rapid response nurse. In this role, I am called on when patients are deteriorating to help to problem-solve and stabilize the patient until the provider can arrive.

Despite the high-stress environment, I remain committed to providing person-centered care. I take the time to understand each patient’s unique needs, involving them in care decisions and ensuring their voices are heard. My compassion and empathy create a therapeutic relationship that contributes to the overall well-being of my patients.

Recognizing the importance of advocating for the nursing profession, I actively participate in initiatives aimed at improving healthcare policies and practices. I engage in professional development, stay informed about advancements in critical care, and advocate for the well-being of both patients and fellow nurses. I embrace change as an opportunity for growth. I also actively seek out training on new technologies, stay informed about evidence-based practices, and contribute to the implementation of innovative approaches in the ICU.

Balancing the emotional toll of critical care nursing with the fulfillment of making a positive impact on patients’ lives can be challenging yet rewarding. I emphasize the importance of self-care and teamwork in navigating the complexities of my role. Though nursing has a multitude of roles and responsibilities that come with providing care to our patients, we must never forget that we also have a responsibility to take care of ourselves.

Caregiver

A caregiver is an individual who provides physical, emotional, or practical support to individuals in need of assistance due to illness, disability, age-related challenges, or other conditions that impact their ability to perform daily activities independently. As a caregiver, one of the primary roles and responsibilities of a nurse is to provide compassionate and holistic care to individuals, families, and communities. This aspect of nursing involves addressing the physical, emotional, social, and psychological needs of patients, with a focus on promoting health, preventing illness, and facilitating healing. Cultural competence is woven into the role, as nurses recognize and respect the diverse backgrounds, beliefs, and values of their patients; tailoring their approaches to care to accommodate individual cultural preferences.

The caregiving role encompasses several key responsibilities, such as assessment, planning, implementation, and evaluation. In the first phase of caregiving, the nurse conducts thorough assessments to understand the unique health circumstances of each individual, considering factors such as health history and environmental influences. Following the assessment, nurses take on the responsibility of developing personalized care plans in collaboration with patients, their families, and the healthcare team. These plans establish specific goals and interventions tailored to the individual’s needs and preferences. In the implementation phase, caregivers carry out the care plan by administering medications, performing treatments, and coordinating various healthcare services. Simultaneously, they provide emotional support and education, aiming to empower patients and their families in their health journey. Nurses also continuously monitor patient health status, evaluate the effectiveness of interventions, and make necessary adjustments to optimize outcomes. Finally, during crises or emergencies, caregivers respond swiftly and effectively to stabilize the patient’s condition. This requires quick thinking, adaptability, and the ability to work effectively under pressure.

Decision-Maker

As a decision-maker, an individual or entity responsible for making choices or reaching conclusions in a particular context, in the healthcare setting, nurses bear a crucial responsibility in influencing and determining various aspects of patient care. At the core of this role is the exercise of clinical judgment. Drawing on their knowledge, experience, and analytical skills, nurses assess patient data, discern patterns, and determine interventions that best address the unique needs of each individual. This process extends to active participation in the development of patient care plans, as nurses collaborate with a diverse healthcare team to establish goals and interventions aligned with patient conditions and preferences.

A central responsibility in the decision-making realm involves prioritization. In the dynamic and often fast-paced healthcare environment, nurses must adeptly discern the urgency and importance of various tasks, ensuring that critical aspects of care receive immediate attention. Resource allocation is another critical facet of the decision-making role. Nurses are tasked with judiciously utilizing limited healthcare resources, including time, staff, and equipment, to optimize care delivery. Adaptation to change is also an essential aspect of decision-making, as nurses must make informed decisions that enable them to navigate shifts in patient conditions, treatment modalities, and healthcare policies.

Clinical Judgment Measurement Model

Take Action: Prioritizing Nursing Care

The nurse is caring for two patients, Mr. Johnson and Mrs. Rodriguez. Mrs. Rodriguez calls out complaining of a “bad headache.” Immediately after, Mr. Johnson rings the call bell complaining that he is having trouble breathing. The nurse quickly assesses Mr. Johnson’s respiratory status, noting increased respiratory rate, use of accessory muscles, and decreased oxygen saturation. Recognizing that respiratory distress can lead to life-threatening complications, the nurse analyzes the severity of the situation and the need for prompt intervention. Applying clinical judgment, the nurse prioritizes care based on the urgency and potential impact on patient outcomes and decides to prioritize addressing Mr. Johnson’s respiratory distress first due to the immediate threat to his physiological stability. The nurse initiates interventions to improve Mr. Johnson’s respiratory status, such as administering supplemental oxygen, positioning for optimal breathing, and notifying the healthcare team for further assessment. The application of clinical judgment in prioritizing nursing care ensures that the most urgent and critical needs are addressed promptly. This structured approach contributes to enhanced patient safety, improved clinical outcomes, and the delivery of person-centered care.

Manager of Care

In the capacity of a manager of care, nurses assume a pivotal role in directing and overseeing the comprehensive delivery of healthcare services. This multifaceted responsibility encompasses various key aspects of patient care coordination and management. Nurses are charged with organizing and optimizing care delivery by planning and prioritizing interventions based on patient needs and available resources. Nurses play a crucial role in coordinating interdisciplinary teams, fostering effective communication and ensuring seamless collaboration among healthcare professionals.

As managers of care, nurses also navigate the complexities of healthcare systems, utilizing their leadership skills to advocate for patients and optimize the use of healthcare resources. This role involves overseeing the implementation of care plans, monitoring patient outcomes, and making timely adjustments to interventions as needed. Furthermore, nurses in this role are instrumental in promoting a culture of safety, quality improvement, and adherence to evidence-based practices within the healthcare setting. Through their managerial responsibilities, nurses contribute significantly to enhancing the overall efficiency, effectiveness, and quality of patient care.

Clinical Safety and Procedures (QSEN)

Embracing QSEN Principles for Effective Management of Patient Care

Quality and Safety Education for Nurses (QSEN) is a cornerstone in shaping the nurse’s role in managing patient care. As nurses take on the responsibility of managing care, the principles of QSEN become fundamental in shaping effective leadership and decision-making to deliver safe and high-quality health care.

Key aspects of QSEN in managing care include the following:

• Patient-centered care: Embracing the principles of QSEN emphasizes the significance of patient-centered care, aligning with the nurse’s role in managing patient care. Nurses ensure that care delivery is personalized to meet individual patients’ needs, preferences, and values, fostering a patient-centric approach.
• Teamwork and collaboration: Effective patient care management requires collaboration among healthcare team members. The QSEN principles advocate for teamwork, encouraging nurses to create a collaborative environment where communication and cooperation thrive, ultimately benefiting patient outcomes.
• Evidence-based practice: As frontline caregivers, nurses play a pivotal role in promoting EBP. The QSEN emphasizes the integration of the latest evidence into decision-making, guiding nurses in adopting practices that are rooted in research and proven to enhance patient safety and care quality.
• Quality improvement: Managing patient care involves overseeing processes for continuous improvement. The QSEN’s focus on quality improvement aligns with the nurse’s responsibility to assess, monitor, and enhance care delivery processes to ensure optimal patient outcomes.
• Patient safety: In the role of managing patient care, nurses are crucial to the success of patient safety initiatives. The QSEN’s focus on safety science guides nurses in implementing strategies to prevent errors, minimize risks, and create a culture of safety within their practice.

The integration of QSEN into nursing care management positively influences patient outcomes. Nurses, equipped with QSEN principles, deliver care based on best practices, contributing to improved patient safety and well-being. The QSEN’s emphasis on communication aligns with the nurse’s role in fostering open and effective communication within the healthcare team. This, in turn, promotes better coordination of care and a more responsive healthcare environment. Nurses, influenced by QSEN’s focus on continuous improvement, are better equipped to adapt to changes in healthcare practices and technologies. This adaptability ensures that patient care remains aligned with the latest advancements.

Communicator

The role of a nurse as a communicator (an individual who engages in the process of conveying information, ideas, or messages to others) is integral to effective healthcare delivery and patient outcomes. Nurses serve as the primary liaisons between patients, their families, and the broader healthcare team, translating complex medical information into understandable and actionable insights. Communication involves not only the dissemination of information but also active listening, empathy, and the fostering of therapeutic relationships. Nurses communicate critical details about patients’ conditions, treatment plans, and progress to other healthcare professionals, ensuring a coordinated and comprehensive approach to care. Additionally, they advocate for patients’ needs and preferences, facilitating shared decision-making in the care process.

The ability to communicate effectively extends to providing emotional support, addressing concerns, promoting health literacy, and empowering patients and their families/caregivers to actively participate in their care. In emergencies or critical situations, nurses must convey information swiftly and clearly to ensure prompt and appropriate interventions. Effective communication is paramount in fostering understanding and trust among patients, families, and the interdisciplinary healthcare team.

Advocate

An advocate is an individual who actively and vocally supports, defends, or promotes the rights, interests, and well-being of another person or a group. The nursing role as an advocate is a cornerstone of person-centered care, reflecting a commitment to safeguarding the rights, well-being, and preferences of individuals within the healthcare system. Nurses serve as vocal proponents for patients, ensuring their voices are heard, concerns addressed, and choices respected. Advocacy involves not only communicating patients’ needs to the healthcare team but also empowering patients to actively participate in decision-making regarding their care. Nurses navigate complex healthcare systems on behalf of patients, assisting them in understanding their rights, treatment options, and available resources (Morris, 2023).

Beyond the individual level, nurses engage in systemic advocacy, contributing to policy discussions and initiatives aimed at improving overall healthcare delivery and outcomes. The advocacy role extends to at-risk populations, where nurses work to address disparities and promote equitable access to quality care. In essence, the nursing responsibility as an advocate is rooted in the principles of justice, autonomy, and beneficence, aiming to ensure that each patient receives the highest standard of care in a supportive and respectful environment.

Educator

The nursing role as an educator (an individual who engages in the process of facilitating teaching and learning) is foundational to promoting health literacy, empowering patients, and fostering informed decision-making. Nurses are entrusted with the responsibility of providing clear and accessible information to patients, their families, and communities. This educational role involves explaining medical conditions, treatment plans, and preventive measures in a comprehensible manner, taking into account individual differences and cultural considerations. Nurses utilize their expertise to enhance patients’ understanding of their health status, medications, and self-care practices.

Beyond the bedside, nurses contribute to community health education, offering insights on disease prevention, healthy lifestyles, and wellness promotion. In the context of chronic conditions, nurses guide patients in managing their health proactively, emphasizing the importance of adherence to treatment plans. By serving as educators, nurses play a vital part in empowering individuals to take an active role in their health, ultimately contributing to better health outcomes and the overall well-being of the communities they serve.

History and Evolution of Nursing Theories

By the end of this section, you will be able to:

• Recognize the evolution of nursing theory
• Identify the elements of a nursing theory
• Discuss the domains of nursing philosophy in relation to clinical practice

A theory is a framework of related ideas intended to guide and support action. A nursing theory, therefore, is a structured and systematic framework composed of concepts, principles, and propositions that collectively guide and shape the understanding of nursing practice. Developed by nursing theorists, nursing theories provide a comprehensive foundation for nurses to conceptualize and interpret various aspects of health care, encompassing not only the delivery of patient care but also education, research, and administration within the nursing profession. At their core, nursing theories articulate fundamental principles and beliefs about the nature of nursing, health, and the dynamic interactions between nurses and their patients. These theories serve as invaluable guides for practitioners, educators, and researchers, contributing to the ongoing evolution and refinement of nursing knowledge and practice in response to the ever-changing landscape of health care (Alligood, n.d.; Gaines, 2023; Wayne, 2023).

The evolution of nursing theory reflects the dynamic nature of the nursing profession, responding to changes in health care, advancements in research, and shifts in societal perspectives. Historically, nursing lacked recognition as an academic discipline or a fully realized profession. Before the development of nursing theories, the profession was characterized as a task-oriented occupation, with nurses operating under the direction and control of the medical profession. The significance of nursing theories lies in their explicit description of nursing, setting the foundation for practice and offering a framework that defines the purpose and role of nurses in healthcare settings. These theories serve as a rationale for nursing interventions, providing scientific reasons and a knowledge base to guide appropriate actions in care situations. Additionally, nursing theories contribute to the ongoing development of nursing practice, offering a basis for the further generation of knowledge and indicating the direction in which the profession should evolve (Alligood, n.d.; Gaines, 2023; Wayne, 2023).

By providing nurses with a sense of identity, nursing theories contribute to the acknowledgment and understanding of the unique contributions that nurses make to the healthcare service, fostering a common language for communication and practice. Nursing theories not only guide research but also influence EBP, contributing to the development of nursing education and training programs. Overall, nursing theories, education, research, and practice are interconnected, mutually influencing and shaping each other as the nursing profession continues to evolve (Alligood, n.d.; Gaines, 2023; Wayne, 2023).

Historical Nursing Theories

The earliest nursing theories emerged in the nineteenth century with the work of pioneers such as Florence Nightingale. Nightingale’s environmental theory (discussed in Nightingale’s Environmental Theory) laid the groundwork for considering the impact of the environment on health. During this period, nursing was primarily seen as a task-oriented and apprenticeship-based profession. In the mid-twentieth century, nursing theories began to take a more systematic and conceptual form. Theories such as Virginia Henderson’s nursing need theory (discussed in Henderson’s Nursing Need Theory) and Hildegard Peplau’s interpersonal relations theory (discussed in Peplau’s Theory of Interpersonal Relations) emphasized the importance of understanding patient needs and interpersonal relationships in nursing practice.

In the late twentieth century, there was a proliferation of nursing theories addressing various aspects of nursing, health, and care. Betty Neuman’s systems model, Dorothea Orem’s self-care deficit nursing theory (discussed in Orem’s Self-Care Deficit Nursing Theory), and Madeleine Leininger’s culture care theory (discussed in Leininger’s Culture Care Theory) are examples of theories developed during this period, reflecting a diversity of perspectives within the field. With the increasing emphasis on EBP, nursing theories have become more integrated with research over time. Theories such as Roy’s adaptation model (discussed in Roy’s Adaptation Model) and the model of nursing as caring by Anne Boykin and Savina Schoenhofer highlight the importance of research in refining and validating theoretical concepts (Alligood, n.d.; Gaines, 2023; Wayne, 2023).

Many contemporary nursing theories in the twenty-first century have emphasized holistic and person-centered care. Theories like Jean Watson’s theory of human caring (discussed in Watson’s Theory of Human Caring) and Patricia Benner’s “novice to expert” model of nursing (discussed in Patricia Benner) underscore the significance of understanding the whole person and the nurse’s role in promoting well-being. In response to increasing globalization and cultural diversity, nursing theories have expanded to incorporate cultural competence and global health considerations. Leininger’s Culture Care Theory and the Transcultural Nursing Model exemplify this shift in focus. The current landscape of nursing theory has also seen an increasing emphasis on interdisciplinary collaboration. Theories, such as the general systems theory (discussed in General Systems Theory), underscore the interconnected nature of systems, which can include not only biological and organizational systems but also interdisciplinary collaborations within the healthcare field.

Throughout their history, nursing theories have adapted to changes in healthcare delivery, technological advancements, and a deeper understanding of human experiences. Theories continue to evolve as nurses and theorists engage with new evidence, technologies, and societal challenges, ensuring the ongoing relevance and advancement of nursing knowledge and practice.

Elements of a Nursing Theory

A nursing theory typically consists of concepts, phenomena, definitions, and assumptions. These key elements work together to form a coherent and comprehensive framework that shapes the understanding and practice of nursing, providing a guide for nurses to approach patient care, education, and research.

Concepts

A concept is an idea that serves as a foundational element of a theory, contributing to its overall structure and coherence. Concepts are like building blocks that capture essential aspects of nursing practice and collectively provide a theoretical framework that guides the profession. Concepts may be abstract, representing general notions rather than specific instances, or concrete, representing specific and tangible ideas or objects that can be directly observed or experienced. Regardless of whether a concept is abstract or concrete, it is accompanied by a precise definition to ensure clarity and consistency in interpretation (Wayne, 2023).

The interrelatedness of concepts within a nursing theory illustrates the dynamic relationships that exist among them, contributing to the theory’s coherence and ability to explain how the concepts influence each other. Concepts must be operationalized to make them observable, relevant, and transferable to research and clinical practice (Wayne, 2023). Examples of concepts that are fundamental to nursing are holism (individuals should be viewed and treated as whole beings), caring (nurses should give patients compassionate and empathetic attention), adaptation (people adjust to changes in the internal and external environments to maintain optimal health), and self-care (activities that individuals perform to maintain their own health and well-being).

Phenomena

A phenomenon is a specific aspect of interest or an observable occurrence that is the focus of theoretical exploration and study. Phenomena in nursing theories refer to whatever theorists seek to understand, describe, explain, or predict within the context of nursing practice. They are often complex and multifaceted, encompassing various dimensions of human health and nursing care (Wayne, 2023).

Examples of phenomena include the experience of pain, coping mechanisms for chronic illness, nurse-patient interactions, health promotion strategies, and cultural competence in nursing. Theories in nursing are developed to explore, describe, explain, or predict these phenomena, providing a structured framework for understanding the complexities of health care. Phenomena are not only the subjects of theoretical exploration but also the catalysts for advancing EBP, guiding nursing research, and enhancing the quality of patient care. As nurses engage with and seek to address phenomena, theoretical frameworks offer valuable perspectives and insights, contributing to the ongoing evolution and refinement of nursing knowledge.

Definitions

A definition is a clear and precise explanation of the meaning attributed to a specific concept or term within the theoretical framework. Definitions serve to establish a shared understanding among theorists, researchers, educators, and practitioners who engage with the theory. The clarity of definitions is essential for consistency in communication and application of the theory across diverse contexts (Wayne, 2023).

Definitions within nursing theories aim to articulate the intended meaning of key concepts, ensuring that these concepts are interpreted and used in a standardized manner. Clear definitions contribute to the conceptual clarity and coherence of a nursing theory, fostering a common language within the nursing discipline. They provide a foundation for theoretical development, research design, and practical application of the theory in clinical settings. As nursing theories evolve, definitions may be refined or expanded to accommodate new insights and understandings within the dynamic field of health care (Wayne, 2023).

Assumptions

An assumption is a foundational belief or proposition that is accepted without direct empirical evidence. For instance, assumptions may revolve around the inherent worth of individuals, the impact of the environment on health, or the nurse’s role in promoting well-being. While assumptions are not subjected to direct testing, they lay the groundwork for the theoretical framework, providing a lens through which the theorist explores, explains, and contributes to the evolving body of nursing knowledge. As nursing theories advance, assumptions may be reevaluated in light of new evidence and insights, ensuring the ongoing relevance and applicability of the theoretical perspectives within the dynamic field of health care (Wayne, 2023).

The Domains of Nursing Philosophy

In its broadest sense, philosophy involves the exploration of fundamental questions about existence, values, and the human experience through critical inquiry and reflection. When applied to nursing, a nursing philosophy becomes the compass that guides a nurse’s practice, encompassing beliefs about the nature of nursing, patient care, ethical considerations, and the nurse’s role within the healthcare system (Alligood, n.d.; Gaines, 2023; Wayne, 2023). Clinical nursing incorporates philosophy by grounding actions in foundational beliefs, proven theories, and EBPs, facilitating a more comprehensive and patient-centered approach to care.

A theoretical domain refers to a broad and overarching area of theoretical exploration or study. It encompasses a set of concepts, assumptions, and other principles that collectively form a comprehensive framework for understanding and explaining phenomena within that particular domain (Wayne, 2023).

The domains of nursing philosophy are commonly articulated through the concepts of person, environment, health, and nursing. These domains provide a framework, known as a metaparadigm, a set of overarching concepts and principles that are key to understanding a particular discipline or field of study. A metaparadigm represents the most abstract level of a theoretical structure and serves as a unifying element that guides the development of theories within the discipline. The nursing metaparadigm is a conceptual framework that emphasizes the interconnectedness of the person, environment, health, and the unique role of nursing in facilitating and optimizing the health and well-being of individuals within their broader contexts (Gaines, 2023; Wayne, 2023).

Perspective on Person

The person domain, often referred to as the patient or client domain, is the central focus of nursing philosophy. This domain emphasizes the individual as a holistic being with physical, psychological, social, cultural, and spiritual dimensions. It acknowledges each individual’s inherent dignity, autonomy, and interconnectedness with the environment (Gaines, 2023; Wayne, 2023).

Nursing philosophy underscores the importance of approaching patients with a person-centered perspective, considering not only their physical health but also their values, preferences, and experiences. Person-centered care recognizes the uniqueness of each individual and aims to provide care that is tailored to their specific needs, values, and preferences. The domain of the person reflects a commitment to providing individualized and culturally competent care that respects the uniqueness of each individual.

Real RN Stories

Recognizing the Importance of Person

Nurse: Gannon, BSN
Clinical setting: Medical-surgical unit
Years in practice: 17
Facility location: Suburban city in Alabama

I specifically remember this particular patient who exemplified the nursing metaparadigm concept of a person. This individual was an older woman facing a complex web of chronic illnesses and emotional challenges. Despite her frailty and physical limitations, she maintained a vibrant spirit and a deep sense of resilience.

As her nurse, my focus extended beyond merely addressing her physical symptoms; it encompassed understanding her unique life history, values, and aspirations. Through therapeutic communication, I discovered her love for painting, which had been a lifelong passion. Recognizing the significance of maintaining her identity beyond the confines of illness, I collaborated with the healthcare team to incorporate art therapy into her care plan. We were able to contact volunteer services and request some crayons, colored pencils, watercolors, and paper. You should have seen her face when I walked in with the supplies. You could see the joy on her face.

This approach not only provided relief from physical discomfort but also cared for her emotional well-being. By acknowledging her as a holistic being with individual needs and aspirations, we created an environment that supported her overall health and quality of life. This experience reinforced my commitment to viewing each patient as a unique person with multifaceted dimensions.

Perspective on Environment

The environment domain encompasses the surroundings, context, and external factors that influence a person’s well-being. This domain recognizes that health is not solely determined by individual factors but is also shaped by the broader physical, social, cultural, economic, and global environment (Table 1.2) (Gaines, 2023; Wayne, 2023). Nurses consider the impact of these environmental factors on the health and well-being of the person and adapt care accordingly.

Table 1.2 Environmental Factors of Health

Perspective on Health

The health domain goes beyond the absence of illness. In nursing philosophy, health is a dynamic and holistic concept that encompasses the overall well-being of the person, including physical, mental, social, and spiritual dimensions. The understanding of health in nursing philosophy is broad, recognizing that individuals exist on a continuum of wellness and that health is influenced by various factors. The focus is on promoting optimal health, which includes preventing illness but also supporting individuals in achieving their highest level of functioning and quality of life (Gaines, 2023; Wayne, 2023).

Health emphasizes preventive measures and wellness promotion, placing a strong emphasis on patient education and empowerment. Cultural sensitivity is paramount, as nursing philosophy recognizes that diverse cultural perspectives influence perceptions of health and that nursing must ensure care aligns with the individual’s cultural beliefs and practices related to health and well-being. By placing the person at the center of care, nurses collaborate with patients to set goals and develop care plans that align with the individual’s personal definitions of health and well-being. By supporting individuals in building resilience and coping mechanisms to maintain or restore their health, nurses may positively influence the individual’s ability to adapt and cope with life’s challenges.

Perspective on Nursing

The nursing domain is a fundamental and central concept that defines the unique role, purpose, and responsibilities of the nursing profession. This domain encompasses the art and science of nursing, outlining the scope of practice and guiding principles that underpin the delivery of care. It captures the essence of the profession, guiding nurses in their dedication to providing high-quality, ethical, and person-centered care that positively impacts the health and well-being of those served (Gaines, 2023; Wayne, 2023).

At its core, nursing is envisioned as a holistic and person-centered discipline, extending beyond the treatment of illness to encompass the promotion of health, the prevention of disease, and the enhancement of overall well-being for individuals and communities. Nurses operate with a commitment to delivering care that is both comprehensive and individualized, recognizing the intricate interplay of physical, emotional, social, cultural, and spiritual dimensions in each person. Advocacy and empowerment are integral elements, with nurses championing the rights and voices of their patients, fostering autonomy, and facilitating shared decision-making. The philosophy underscores the importance of health promotion, compassionate interactions, and continuous pursuit of knowledge through evidence-based practices. Ethical considerations form a foundation for nursing practice, emphasizing integrity, confidentiality, and delivery of care that aligns with moral principles.

Relation to Clinical Judgment

You have seen the term clinical judgment several times in this chapter, but what exactly does it mean? Essentially, clinical judgment utilizes nursing knowledge, critical thinking, and clinical reasoning, drawing from evidence, theories, and interdisciplinary insights to make informed and patient-centered decisions. It involves the practical application of the domains of nursing philosophy: person, environment, health, and nursing. Together, these domains comprise a conceptual framework that informs clinical judgment, guiding nurses to make sound decisions and provide effective care. They provide a holistic perspective, emphasizing individualized care, consideration of environmental influences, promotion of health, and adherence to the principles of nursing.

More concretely, clinical judgment involves the nurse’s ability to assess and understand the unique characteristics, needs, and responses of each individual receiving care. By recognizing the holistic aspects of the person, including their physical, emotional, social, and cultural dimensions, nurses can make informed and person-centered decisions, tailoring interventions to the individual’s specific context. Clinical judgment also requires nurses to consider environmental factors—including the patient’s physical, social, and cultural contexts—when assessing and planning care. Understanding the impact of the environment on an individual’s health and well-being helps nurses adapt interventions, identify potential challenges, and create a setting conducive to optimal patient outcomes. The domain of health guides nurses in setting goals, preventing complications, and promoting well-being. Continually assessing the patient’s health status enables the nurse to determine the most appropriate intervention at a given time. Finally, the domain of nursing directly informs clinical judgment by defining the scope of nursing practice. Nurses draw on their knowledge, skills, and ethical principles to make decisions aligned with the philosophy of nursing.

Clinical Judgment Measurement Model

Take Action: Using Clinical Judgment to Address Environmental Factors

A patient recovering from surgery was becoming increasingly agitated and disoriented. The attending nurse recognized environmental cues in the room such as loud noises, bright lights, and constant interruptions in sleep and concluded the patient was likely experiencing delirium. The nurse collaborated with the healthcare team to adjust the environment, such as reducing the noise level, dimming the lights in the room, and clustering care so the patient could sleep with fewer interruptions. After implementing these strategies, the nurse noted significant improvements to the patient’s mental clarity and overall well-being, demonstrating the importance of recognizing and addressing environmental factors in patient care.