CONTENTS
Foreword
Preface
Editors’ Introduction
Acknowledgments
Review of the Nursing Field
The Nursing Profession: Development, Challenges, and Opportunities
A Brief History of Nursing
The Nursing Profession
Current Issues and Challenges
Opportunities: A Vision For The Future
The History of Nursing and the Role of Nurses
Chapter 1: Notes On Nursing: What It Is, And What It Is Not
Chapter 2: The Nature of Nursing
Development of A Concept
Unique Function
Nursing Practice
Nursing Research
Nursing Education
Summary
Chapter 3: A Caring Dilemma: Womanhood and Nursing in Historical Perspective
The Meaning of Caring
Caring As Duty
The Professed Nurse
The Hospital Nurse
The Influence of Nightingale
The Contradictions of Reform
A Different Vision
Beyond The Obligation To Care
Altruism With Autonomy
Chapter 4: Nursing as Metaphor
Chapter 5: Stages of Nursing’s Political Development: Where We’ve Been and Where We Ought to Go
Stage 1
Stage 2
Stage 3
Stage 4
In Pursuit of Stage 4
Conclusion
Acknowledgments
Chapter 6: Knowledge Development in Nursing: Our HistoricAL Roots and Future Opportunities
The Early Years
The Transition Years
Nursing Research Becomes Nursing Science
Future Opportunities
Acknowledgments
Nursing Education and Training
Chapter 7: The Goldmark Report
The Nurse in Public Health
Hospital Training School
Chapter 8: Career Pathways in Nursing: Entry Points and Academic Progression
Traditional Entry Points into Nursing
Emerging Entry Points
Moving Along The Education Continuum
Conclusion
Chapter 9: Nursing the Great Society: The Impact of the Nurse Training Act of 1964
Influences Inside Nursing
Influences Outside Nursing
Public and Private Activism
How A Private Agenda Became Public Policy
The Political Climate Chills
Growth On Two Levels
Nursing’s Aspirations
Afterword
Acknowledgments
Advanced Practice Nursing
Chapter 10: Role and Quality of Nurse Practitioner Practice: A Policy Issue
Chapter 11: Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial
Methods
Results
Comment
Acknowledgment
Chapter 12: Nurse-Midwives and Nurse Anesthetists: The Cutting Edge in Specialist Practice
Brief History
Nurses Or Something Else
Complement Or Substitute?
Money
Conclusions
Acknowledgments
Chapter 13: Lessons Learned from Testing the Quality Cost Model of Advanced Practice Nursing (APN) Transitional Care
The Quality Cost Model of APN Transitional Care
What Has Been Learned
Questions Remaining To Be Answered
Chapter 14: Reaching Consensus on a Regulatory Model: What Does This Mean for APRNs?
How Did This Historic Agreement Come About?
What is The New Aprn Regulatory Model?
What Does This Mean To Currently Licensed APRNS?
How Will The Model Impact NP Education, Certification, and Licensure?
Implementation of The Model
How Will A Uniform Regulatory Model Impact APRNS?
The Nursing Workforce/Nursing Shortages
Chapter 15: Implications of an Aging Registered Nurse Workforce
Methods
Results
Comment
Acknowledgments
Chapter 16: Global Nurse Migration
Migration and The Global Healthcare Workforce
Policy Implications For The U.S. Nursing Workforce
Summary
Quality, Safety, and Cost
Chapter 17: Nurse-Staffing Levels and the Quality of Care in Hospitals
Methods
Risk Adjustment and Characteristics of The Hospitals
Results
Discussion
Acknowledgments
Chapter 18: Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction
Methods
Results
Comment
Acknowledgments
Chapter 19: Nurse Staffing in Hospitals: Is There a Business Case for Quality?
Study Data and Methods
Acknowledgments
Specialty Practice in Nursing
Chapter 20: Long-Term Care Policy Issues
Poor Quality of Care and Weak Regulatory Enforcement
Inadequate Nursing Home Staffing Levels
Nursing Facility Reimbursement Reform
Corporate Ownership Transparency
Home and Community-Based Services
Public Financing of Long-Term Care
Summary
Chapter 21: The Future of Home Care
The Legacy of Home Care
Medicare: Home Care’s Second Coming
Reining in A Benefit Out of Control
Home Care’s Future
Chapter 22: Follow the Money: Funding Streams and Public Health Nursing
The Perspective of Public Health
Changes Over Time
Financing Public Health
The Impact on Nursing
Health Reform and Managed Care
What About Nursing?
Chapter 23: Swamp Nurse
Chapter 24: Role of the School Nurse in Providing School Health Services
School Nurse Definition
Background
School Nurse Role
School Nurse Activities
School Health Services Team
Professional Preparation For School Nurses
Conclusion
Recommendations
Afterword
The Editors
Cover Photo: The Evolving Face of Nursing
Mural by Meg Seligman
Photo by Steven Weinik
For years, the most popular mural in Philadelphia, the “city of murals,” was the nursing mural (“A Tribute to Nursing”) on the side of a building at Broad and Vine Streets. That mural focused on the history of nursing rather than its future. When the wall became compromised, the city enlisted the support of the Independence Foundation and others to commission a new nursing mural by internationally known muralist Meg Seligman. After interviewing many nurses who spoke about the various dimensions of their current work and opportunities for innovations in health care, Seligman designed a mural that focused on contemporary nursing with links to its past and future. Titled “The Evolving Face of Nursing,” the 6,500 square foot mural incorporates the faces of nurses and key images that convey the intellectual, creative, and emotional work of nursing through images and symbols. This dynamic mural changes color and emphasis at night through the use of LED lighting—a feature that Seligman used for the first time in this mural. The mural was unveiled on October 6, 2010. The cover photograph by Philadelphia-based photographer, Steven Weinik, shows its location within the community, symbolizing the work of diverse nurses with individuals, families, and communities.
Copyright © 2011 by the Robert Wood Johnson Foundation, Route One and College Road East, Princeton, New Jersey 08543. All rights reserved.
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With the exception of the chapter by Diana Mason, no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, or on the Web at www.copyright.com. Requests to the publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, 201-748-6011, fax 201-748-6008, or online at www.wiley.com/go/permissions.
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Library of Congress Cataloging-in-Publication Data
The nursing profession : development, challenges, and opportunities / editors, Diana J. Mason, Stephen L. Isaacs, David C. Colby; foreword by Risa Lavizzo-Mourey. — 1st ed.
p.; cm. — (Robert Wood Johnson foundation health policy series) Complements: The future of nursing / Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institue of Medicine. c2011.
Includes bibliographical references.
ISBN 978-1-118-02881-0 (pbk.); 978-1-118-12220-4 (e-bk.); 978-1-118-12221-1 (e-bk.); 978-1-118-12222-8 (e-bk.)
1. Nursing—Practice—United States. 2. Nursing—United States. 3. Leadership—United States.
I. Mason, Diana J., 1948- II. Isaacs, Stephen L. III. Colby, David C. IV. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. Future of nursing. V. Series: Robert Wood Johnson Foundation series on health policy.
[DNLM: 1. Nursing—trends—United States—Collected Works. 2. Nurse’s Role—United States—Collected Works. WY 16 AA1]
RT82.N8684 2011
610.73—dc22
2011006933
We dedicate this book to the memory of C. Patrick Crow, who died shortly after editing its lead chapter. Over the course of the past fifteen years, Pat edited both the Robert Wood Johnson Foundation Anthology and its Series on Health Policy. He was an extraordinary editor and, even more important, an exemplary human being. We shall miss him.
SLI, DCC, DJM
FOREWORD
Like the other four books in the Robert Wood Johnson Foundation Health Policy Series,1 The Nursing Profession: Development, Challenges, and Opportunities focuses on a discipline or profession that has been a Foundation priority for many years. Strengthening the nursing profession has been of central importance to the Robert Wood Johnson Foundation over its nearly forty-year existence, and we have devoted more than $200 million to the growth and improvement of nursing education and practice. Our dedication to nursing continues the legacy of our founder. In his personal philanthropy and as the head of his own New Brunswick-based foundation, Robert Wood Johnson was genuinely interested in improving nursing, and gave generously to amplify the role of nurses in improving health. The foundation that bears his name has sustained that commitment.
As far back as 1973, the Foundation awarded a series of grants to develop an emerging field—nurse practitioners—an idea that was, at the time, untested and controversial. These grants demonstrated that nurse practitioners could provide high-quality primary care services in remote rural areas and underserved inner cities. Since that time, the Robert Wood Johnson Foundation has invested in:
- Strengthening nursing school faculty and leadership
- Addressing nursing shortages
- Improving the nursing workforce
- Conducting research on nursing
- Developing public health nursing
- Establishing nurse-run school health centers
- Improving hospital nursing
And this is only a partial list.
The Nursing Profession: Development, Challenges, and Opportunities begins with a comprehensive review of the nursing field by Diana Mason, the Rudin Professor of Nursing at the Hunter-Bellevue School of Nursing, City University of New York, and former editor-in-chief of the American Journal of Nursing. Mason’s chapter is followed by reprints of twenty-four of the most influential or significant articles on nursing—some of them classic pieces dating back to Florence Nightingale, others presenting more current thinking on critical issues. This source material is rarely found in one place.
The Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine (IOM) issued its report in October 2010. It sets forth a blueprint for nursing that can guide policymakers and those in the health care professions. We hope that The Nursing Profession: Development, Challenges, and Opportunities will be a worthy companion to the IOM report. Both publications illustrate our dedication to improving a field that is so critical to the nation’s health and are especially timely, because “a reformed health care system must include an adequate supply of well-trained professionals who can deliver care to all Americans. Nurses are at the center of this discussion.”2 I am pleased and proud that the Robert Wood Johnson Foundation has played an important role in nursing’s development and will continue to do so in the future.
Risa Lavizzo-Mourey, MD, MBA
President and CEO
The Robert Wood Johnson Foundation
Princeton, New Jersey
May 2011
NOTES
1. Isaacs, S. L., & Knickman, J. R., (Eds). Generalist medicine and the U.S. health system. San Francisco: Jossey-Bass, 2004; Lear, J. G., Isaacs, S. L., & Knickman, J. R. (Eds). School health services and programs. San Francisco: Jossey-Bass, 2006; Warner, K. E., Isaacs, S. L., & Knickman, J. R. Tobacco control policy. San Francisco: Jossey-Bass, 2008; Meier, D. E., Isaacs, S. L., & Hughes, R. G., (Eds). Palliative care: Transforming the care of serious illness. San Francisco: Jossey-Bass, 2010.
2. Rother, J., & Lavizzo-Mourey, R. Addressing the nursing shortage: A critical element in health reform. Health Affairs 28, w260–w264 (2009).
PREFACE
SUSAN B. HASSMILLER
Susan B. Hassmiller, PhD, RN, FAAN, serves as the Robert Wood Johnson Foundation Special Adviser on Nursing and Director of the Initiative on the Future of Nursing.
May we hope that, when we are all dead and gone, leaders will arise who have been personally experienced in the hard, practical work, the difficulties, and the joys of organizing nursing reforms, and who will lead far beyond anything we have done!
—Florence Nightingale
The Robert Wood Johnson Foundation and Institute of Medicine (IOM) became partners in 2008 to develop the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the IOM. A core product of the Initiative was an IOM report called The Future of Nursing: Leading Change, Advancing Health, which was issued in October 2010.1 The report examined the capacity of the nursing workforce to meet the demands of a newly reformed health care system, keeping in mind the needs of an aging population and the emphasis on care in the community. It made a series of recommendations that address a range of public policy and system changes, including vital roles for nurses in designing and implementing a more effective and efficient health care system. The committee’s ultimate goal was to improve patient care and health care outcomes.
The Robert Wood Johnson Foundation has continued the Future of Nursing Initiative by partnering with AARP to facilitate a national campaign to encourage the adoption of the recommendations, and as stakeholders in the nursing and policy communities feel the need, come up with additional recommendations or priority areas on which to work. We will continue to raise the notion of the value to society of investing in a strong, well-educated, and empowered nursing workforce. Partners in this campaign include leaders from government, business, policy, academia, medicine, and of course, nursing. A National Summit on Advancing Health through Nursing was held in Washington, DC, at the end of November 2010, to mark the official start of the campaign.
The IOM committee working on the report was heavily influenced by the best thinking of those who study and practice nursing, including authors of the articles reprinted in The Nursing Profession: Development, Challenges, and Opportunities. I can think of no better place for those who are interested in or touched by nursing to gain an understanding of the history of the current issues facing the nursing profession than this anthology. It is my sincere hope that readers of this book will be inspired by the authors—both past and present—who influenced the field.
Together, The Future of Nursing: Leading Change, Advancing Health report and The Nursing Profession: Development, Challenges, and Opportunities lay the groundwork for understanding where the field has been, where it stands currently, and where it needs to go in the future in order to address the issues facing nursing and improve the health of all Americans.
NOTE
1. http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
EDITORS’ INTRODUCTION
DIANA J. MASON, STEPHEN L. ISAACS, AND DAVID C. COLBY
This book is designed to be a resource for those who are interested in or touched by nursing. We have tried to capture the field in a single volume and to share the best thinking of those who study and practice it. Readers—whether researchers or practitioners, foundation or government officials, students, or simply laypeople interested in nursing—should use this volume to gain a better understanding of the nursing profession and the issues with which those in the field and related fields are grappling.
An initial challenge for the editors was determining how to present the wealth of information in an engaging, readable way—one that would satisfy both those deeply knowledgeable in the field as well as those less familiar with nursing. This challenge was relatively easy to overcome because The Nursing Profession: Development, Challenges, and Opportunities is the fifth volume in a series whose format, according to the reviews, appears to be working. We adopted that format, one that consists of a comprehensive review article, followed by reprints of the twenty-four or so most influential or important articles in the field.
Finding a knowledgeable, highly respected expert on nursing—one who is a good writer to boot—to do a comprehensive review of the field presented a second challenge. Fortunately, one of us—Diana Mason—met all of the requisites, and she has written the lead chapter, which covers the field in its entirety (with the exception of the specifics of clinical nursing). Among the topics that Dr. Mason covers are:
- The history of nursing
- The nursing profession
- Current issues and challenges, including the nursing shortage, educating and training nurses, utilizing advanced practice nurses to their fullest, quality and cost, long-term care, community-based care, gender and power, and new areas for nursing
- A vision for the future
The most daunting challenge, not surprisingly, turned out to be selecting the articles or book chapters for reprint. How to choose twenty-four that represent the most important or influential in a field with such an extensive, high-quality literature? As a first step, we asked more than thirty experts for their top picks. From their suggestions, plus those gleaned from our own experience and literature reviews, we compiled an initial list of roughly 200 articles or book chapters that were potential reprint candidates.
The three editors discussed each of the articles and winnowed the list gradually. We wanted to be sure to include pieces that were of historical importance (such as a selection from Florence Nightingale’s Notes on Nursing and the Goldmark Report), that influenced the field (such as Mary Mundinger’s article on nurse practitioners in the Journal of the American Medical Association and Linda Aiken’s article, also in JAMA, on hospital nursing), that captured basic aspects of the profession (such as Susan Reverby’s article on womanhood and nursing and Claire Fagin and Donna Diers’ short commentary, Nursing as Metaphor), and that synthesized issues in a clear and compelling manner (for example, the articles by Peter Buerhaus and colleagues on the nursing shortage and by Connie Mullinex and Dawn Bucholtz on nurse practitioners). We organized the reprints by topic, roughly following the major themes presented in Mason’s review chapter and tried, though with only partial success, to strike an equitable balance in the number of reprints within each category.
We realize that many worthy pieces are not included in the twenty-four that are reprinted in the book. It is likely that another team of editors would have come up with a somewhat different list of reprints. We believe, however, that the final list represents a fair sample of the most important and influential articles in the nursing field.
As Risa Lavizzo-Mourey observed in her foreword, this book is designed in part to complement the report by the Institute of Medicine on the future of nursing. In that regard, we are honored to have a preface by Susan Hassmiller, the executive director of the IOM’s Initiative on the Future of Nursing, and an afterword by Donna Shalala and Linda Burnes Bolton, the chair and vice chair of IOM committee that prepared the report.
With the passage of Patient Protection and Affordable Care Act in 2010 and its implications for the way health services are delivered, the condition of nursing in our nation will be more important than ever. The combination of the IOM report and this book will, we hope, promote greater understanding of the nursing field; educate the nursing, health care, student, and policy communities, as well as the interested public; and help inform a nursing agenda that will lead to improving the health and well-being of all Americans.
ACKNOWLEDGMENTS
We are particularly grateful to David Keepnews for his in-depth, detailed reviews of two drafts of the opening chapter to the book. He also recommended writings for us to consider, as did the following people: Patricia Archbold, Geraldine “Polly” Bednash, Patricia Benner, Amy Berman, Peter Buerhaus, Mary Chaffee, Sally Cohen, Donna Diers, Claire Fagin, Patty Franklin, Kristine Gebbie, Catherine Gilliss, Charlene Harrington, Susan Hassmiller, Maureen “Shawn” Kennedy, Christine Kovner, Ellen Kurtzman, Afaf Meleis, Mathy Mezey, Mary Naylor, Susan Reinhard, Marla Salmon, Ellen Sanders, Nancy Sharp, Julie Sochalski, Virginia Tilden, Marita Titler, Antonia Villarruel, Colleen Conway-Welch, and Patricia Yoder-Wise. The final decision on which articles to reprint was made solely by the editors, taking into consideration the guidance of these experts.
At the Robert Wood Johnson Foundation, we wish to acknowledge David Morse and Fred Mann for their wise counsel, Sarah Pickell for her research and editorial assistance, Mary Beth Kren for locating source materials, Rose Littman for facilitating communications among the editors, Hope Woodhead and Sherry DeMarchi for overseeing the book’s distribution, Mimi Turi for managing the budget and contract arrangements, and Risa Lavizzo-Mourey for her support and guidance.
We also recognize the work of Shirley Tiangsing in translating printed text of the reprints into an electronic format.
Elizabeth Dawson, research and editorial director at Health Policy Associates, did outstanding work in conducting research, overseeing the production process, proofreading, and resolving with great aplomb all of the problems that arose. We are very appreciative of her efforts.
DJM, SLI, DCC
REVIEW OF THE NURSING FIELD
An Original Article
Diana J. Mason, “The Nursing Profession: Development, Challenges, and Opportunities”