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2018v1.0
Professional Nursing
Concepts & Challenges
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Professional Nursing
Concepts & Challenges
Ninth Edition
Beth Perry Black, PhD, RN, FAAN

Associate Professor
University of North Carolina at Chapel Hill
School of Nursing
Chapel Hill, North Carolina
3251 Riverport Lane
St. Louis, Missouri 63043
PROFESSIONAL NURSING: CONCEPTS & CHALLENGES,

NINTH EDITION ISBN: 978-0-323-55113-7
Copyright © 2020, Elsevier Inc. All Rights Reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
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Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. Because of rapid advances
in the medical sciences—in particular, independent verification of diagnoses and drug dosages—should
be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or con-
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Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

I dedicate this edition to my smart, funny, and spirited daughters, Amanda and Kylie,
who, like their mom, chose their life partners well. Thank you,
Hudson and Pierce, for becoming family.
—BPB
CONTRIBUTORS
Maureen J. Baker, BSN, MSN, PhD Beverly Brown Foster, MN, MPH, PhD, RN
Clinical Associate Professor Clinical Professor
University of North Carolina at Chapel Hill School of Nursing
Chapel Hill, North Carolina University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
Josie K. Christian, DNP, MSN, BSN, RN, PHN
Chair and Associate Professor Heather Moulzolf, DNP, MA-N, BA-N,
Nursing Department ARNP-BC, CNP-BC
Concordia University Saint Paul Assistant Professor
St. Paul, Minnesota Nursing - RN to BSN
Concordia University
Janna Louise Dieckmann, BA, BSN, MSN, PhD Saint Paul, Minnesota;
Clinical Associate Professor Associate Professor
School of Nursing Nursing - DNP
University of North Carolina at Chapel Hill St. Catherine University
Chapel Hill, North Carolina Saint Paul, Minnesota
Maxine Fearrington, MS, RN-BC Anita Tesh, BSN, MSN, PhD, CNE, ANEF, RN
Level III RN Assistant Dean
Strong Surgical Center Undergraduate Division, School of Nursing
University of Rochester Medical Center University of North Carolina at Chapel Hill
Rochester, New York Chapel Hill, North Carolina; Adjunct Professor
School of Nursing
Kimberly Fenstermacher, PhD University of North Carolina at Greensboro
Chair, Department of Nursing Greensboro, North Carolina
Associate Professor
School of Science, Engineering and Health
Messiah College
Mechanicsburg, PA
vi
REVIEWERS
Amy Holland, RN, MSN Linda Jean Porter-Wenzlaff, RN, LPC-S, PhD, MSN,
Clinical Instructor MA, CENP, NEA-BC, CNE, NCC
School of Nursing Lillie Cranz Cullen Endowed Professorship in Nursing,
University of Texas Distinguished Teaching Professor, Clinical
Austin, Texas Office of Faculty Affairs and Diversity
School of Nursing
Josie K. Christian, DNP, MSN, BSN, RN, PHN UT Health San Antonio
Chair and Associate Professor San Antonio, Texas
Nursing Department
Concordiau University Saint Paul Lynnann Baumann Murphy, MN, BSN, RN
St. Paul, Minnesota Faculty Instructor
Leach College of Nursing
Gina M. Oliver, PhD, APRN, FNP-BC, CNE University of St. Francis
Associate Teaching Professor Joliet, Illinois
Sinclair School of Nursing
University of Missouri
Columbia, Missouri
vii
P R E FA C E
Nursing is evolving, as is health care, in the United States. using contributors with content expertise, this edition
With the debates and discussions, lawsuits, and legis- remains fresh and up-to-date. The effects of social media
lation that surround the Affordable Care Act (ACA), on nursing are addressed extensively regarding the legal
health care has become a flashpoint in American polit- and ethical implications of their use by nurses and their
ical and social discourse. With the increasing response role in professional socialization and communication.
to calls to advance their education and with their strong With the easy and free availability of health-related
record of safety and quality care, nurses are well situ- statistics from .gov and other websites, I and the con-
ated to be leaders in the provision of health care in the tributors decided to continue with the plan that was suc-
United States. cessful in the eighth edition: more narrative and fewer
To be effective leaders, nurses must master knowl- statistics. I have rarely met an engaged nurse who didn’t
edge about health and illness and human responses start a story with, “I had a patient once who…” These
to each, think critically and creatively, participate in narratives teach us about what is important in nursing.
robust interprofessional education and collaborations, Throughout the book, we have been very careful to
be both caring and professional, and grapple with com- be inclusive, to avoid heteronormative and ethnocentric
plex ethical dilemmas that challenge providers in a time language, to use examples that avoid stereotypes of all
when health care resources are strained. As leaders, types, and to include photographs that capture the won-
nurses should understand their history because the past derful diversity of American nursing.
informs the present; vision for the future builds on the A note about references: older references refer to
lessons of today. classic papers or texts. There are a few references that
The ninth edition of Professional Nursing: Concepts & do not reach the level of “classic” texts, but the author
Challenges reflects my commitment to present current turned a phrase in a clever or elegant way that needed
and relevant information. Since the last edition, the ACA to be cited. No manner of updated paper could replace
has been subject to attempts to defund it, destabilize the these interesting comments or points of view. Research
insurance markets, and change key components of this and clinical works are relevant and contemporary.
important legislation, including doing away with protec- As with the last four editions, the ninth edition is
tions of persons with preexisting conditions. By the time written at a level appropriate for use in early courses in
this edition is published, the 2018 midterm elections baccalaureate curricula, in RN-to-BSN and RN-to-MSN
will have taken place and some of the questions that now courses, and as a resource for practicing nurses and grad-
trouble the ACA and health care in general are likely to uate students. An increasing number of students in nurs-
have been resolved in one way or another. Although at ing programs are seeking second undergraduate degrees,
the time of this writing the future of the ACA is unclear, such as midlife adults seeking a career change and oth-
what is clear is that questions of health care as a human ers who bring considerable experience to the learning
right and how health care is best delivered and paid for situation. Accordingly, every effort has been made to
will continue to spark lively debate in America. present material that is comprehensive enough to chal-
In this edition, the order of the chapters has remained lenge users at all levels without overwhelming beginning
the same as in the eighth edition, based on generous students. The text has been written to be engaging and
feedback from faculty that this order provides a cohe- interesting, and care has been taken to minimize jargon
sive view of nursing; its history, education, and con- so prevalent in health care. A comprehensive glossary is
ceptual and theoretical bases; and the place of nursing provided to assist in developing and refining a profes-
in the U.S. health care system. Faculty are encouraged, sional vocabulary. As in previous editions, key terms are
however, to use the chapters in any order that reflects highlighted in the text itself. All terms in color print are
their own pedagogic and theoretical approaches. By in the Glossary. The Glossary also contains basic terms
viii
PREFACE ix
that are not necessarily used in the text but may be unfa- Professional Nursing: Concepts & Challenges, Ninth Edi-
miliar to students new to nursing. tion, will contribute to the continuing evolution of the
I hope that the ninth edition continues to meet the profession of nursing and, ultimately, to the excellent
high standards set forth by Kay Chitty, who edited the care of patients, their families, and their communities.
first four editions of this book. I hope that students and
faculty will find this edition readable, informative, and Beth Perry Black
thought provoking. More than anything, I hope that
ACKNOWLED GMENT S
With each new edition of Professional Nursing: Concepts • T o the faculty and students at Guangzhou (PRC)
& Challenges, I find myself increasingly in awe of the University School of Nursing and Traditional Chi-
intelligence, creativity, humility, and work ethic of the nese Medicine, especially Jiagen Xiang, whom I am
nurses who continue to inspire me. proud to have as my colleague and friend.
I am grateful to the many people whose support and • To Claudia Christy, my friend and traveling compan-
assistance have made this book possible, each in differ- ion across the years, whose common sense and keen
ent ways: intelligence are a formidable combination.
• To faculty who used earlier editions and shared their • To Bonnie Barbour, whose friendship in our child-
helpful suggestions to make this book better. hood and now again as (not-quite!) seniors is a trea-
• To students who sent e-mails, expressing their grat- sure.
itude for an interesting and readable textbook while • To my brothers Dennis, David, and Mike Perry,
offering ideas for improvement. because I would be lost without my bros.
• To the contributors in this edition—Anita, Bev, • To my nieces Kelsey and Olivia. You are lights in my
Maureen, Janna, Kimberly, Maxine, Heather, Josie— life, girls.
whose expertise and commitment to excellence has I am so lucky to have each of you grace my life with
made working on this edition particularly enjoyable. your unique gifts. I can’t thank you enough.
• To my colleagues in the School of Nursing at the
University of North Carolina at Chapel Hill, and to
our extraordinary nursing students and alumni, who
make us proud.
x
CONTENTS
1 Nursing in Today’s Evolving Health Care Environment, 001
2 The History and Social Context of Nursing, 028
3 Nursing’s Pathway to Professionalism, 057
4 Nursing Education in an Evolving Health Care Environment, 073
5 Becoming a Professional Nurse: Defining Nursing and Socialization Into Practice, 096
6 Nursing as a Regulated Practice: Legal Issues, 117
7 Ethics: Basic Concepts for Professional Nursing Practice, 139
8 Conceptual and Philosophical Foundations of Professional Nursing Practice, 171
9 Nursing Theory: The Basis for Professional Nursing, 198
10 The Science of Nursing and Evidence-Based Practice, 217
11 Developing Nursing Judgment through Critical Thinking, 239
12 Communication and Collaboration in Professional Nursing, 259
13 Nurses, Patients, and Families: Caring at the Intersection of Health, Illness, and Culture, 285
14 Health Care in the United States, 311
15 Political Activism in Nursing: Communities, Organizations, and Government, 341
16 Nursing’s Challenge: To Continue to Evolve, 361
Epilogue, 372
Glossary, 373
Index, 385
xi
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1
Nursing in Today’s Evolving
Health Care Environment
Heather Moulzolf, DNP, MA-N, BA-N, ARNP-BC, CNP-BC,
Josie K. Christian, DNP, MSN, BSN, RN, PHN
To enhance your understanding of this chapter, try the Student Exercises on the Evolve site at
http://evolve.elsevier.com/Black/professional.
LEARNING OUTCOMES
After studying this chapter, students will be able to: • Identify evolving practice opportunities for nurses.
• Describe the demographic profile of registered • Consider nursing roles in various practice settings.
nurses today. • Explain the roles and education of advanced practice
• Recognize the wide range of settings and roles in nurses.
which today’s registered nurses practice.

Nurses comprise the largest segment of the health care Act (PL 111-148) and the Health Care and Education
workforce in the United States and have increasing Affordability Reconciliation Act (PL 111-152). These
opportunities to practice in a wide variety of settings. In laws provide for incremental but progressive change
fact, nurses specialize in 104 areas: 34 specialties are out- to the way that Americans gain access to and pay for
side the hospital, 68 are research oriented, 37 are man- their health care. Although likely to be revised to some
agerial, and 92 are patient facing (see the Campaign extent by Congress, the ACA has nonetheless provided
for Nursing Explore Specialties at https://www.discov- increased opportunities for nurses: the Committee on
ernursing.com/explore-specialties#.WhXOF0qnE2w). the Robert Wood Johnson Foundation (RWJF) Initia-
More than ever, the profession requires a well-trained, tive on the Future of Nursing at the National Academy
flexible, and knowledgeable workforce of nurses who of Medicine (formerly the Institute of Medicine [IOM])
can practice in today’s evolving health care environment. noted, “Nurses have a considerable opportunity to act
Recent legislation, demands of patients as consumers of as full partners with other health professionals and to
health care, and the need to control costs while optimiz- lead in the improvement and redesign of the health care
ing outcomes have had a great influence on the way that system and its practice environment” (Institute of Med-
health care is delivered in the United States. Nursing is icine, 2010, pp. 1–2). This important initiative continues
evolving to meet these demands. to have a profound influence on the evolution of nursing
One of the most notable influences on today’s health and nursing education since its publication.
care environment is the Affordable Care Act (ACA), Writing about “nursing today” poses a challenge,
passed in 2010 by the 111th Congress and signed into because what is current today may have already
law by President Barack Obama. The ACA is actually changed by the time you read this. What does not
two laws—the Patient Protection and Affordable Care change, however, is the commitment of nurses to what
1
2 CHAPTER 1 Nursing in Today’s Evolving Health Care Environment
Rosenberg (1995) referred to as “the care of strang- useful survey. The final version of the 2008 federal nurs-
ers”—professional caring, learned through focused ing workforce survey, The Registered Nurse Population:
education and deliberate socialization (Storr, 2010). In Findings from the 2008 National Sample Survey of Reg-
other words, you will be taught to think like a nurse and istered Nurses (U.S. Department of Health and Human
to do well those things that nurses do. You will become Services, 2010), is available as a .pdf file in a direct link:
a nurse. Importantly, some of you are already nurses https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/
and are returning to school to further your education. rnsurveyfinal.pdf.
Thank you for your commitment to the profession and In response to the discontinuation of the NSSRN and
to your own professional development! You have expe- the ongoing need to understand the nursing workforce,
rienced firsthand the shifting needs of the profession in in 2013 the National Council of State Boards of Nursing
response to an evolving health care system in a chang- (NCSBN) and the Forum of State Nursing Workforce
ing world and are poised to move nursing forward with Centers (FSNWC) combined efforts to conduct a com-
your knowledge from both your education and your prehensive national survey of RNs (Budden et al., 2013).
wide variety of experiences. In this chapter, data from the 2015 NCSBN and FSNWC
In this chapter you will learn some basic information survey are presented in conjunction with other sources
about today’s nursing workforce: who nurses are, the of workforce data, including the final 2008 NSSRN data,
settings where they practice, and the patients for whom to provide you with a thumbnail sketch of nursing, spe-
they are providing care. You will also be introduced to cifically focusing on the number of nurses in the work-
some nurses who have had intriguing experiences and force, as well as their gender, age, race, ethnicity, and
opportunities that you may not know are even possible. educational levels.
Your nursing education will provide you with a flexible
set of skills and opens to you a wide variety of experi- Nurses in the Workforce
ences that await you as you begin—or continue—your RNs are the largest group of health care providers in the
career as a professional registered nurse (RN). United States and in the 2000s grew by 24.1% (Health
Resources and Services Administration, 2013). More
than 4 million individuals held licenses as RNs in 2016
NURSING IN THE UNITED STATES TODAY (National Council of State Boards of Nursing, 2016). In
High-quality, culturally competent nursing care depends 2013 approximately 2.8 million nurses were currently
on a culturally diverse nursing workforce (American working (Health Resources and Services Administra-
Association of Colleges of Nursing [AACN], 2014a). The tion, 2013). In the 2015 NCSBN and FSNWC National
need to enhance diversity in nursing through the recruit- Workforce Survey of RNs, the majority (91%) of nurses
ment of underrepresented groups into the profession is a younger than age 50 are employed in nursing. A signifi-
priority (AACN, 2014b). Understanding the composition cant number of survey respondents (82%) were actively
of the nursing workforce is necessary to identify under- employed in nursing, with 63% reporting working full
represented groups and to recognize workforce trends time. Respondents worked an average of 36.6 hours per
such as the age of nurses in practice and the percentage of week (one position), and RNs with two or more posi-
licensed nurses holding jobs in nursing. tions worked an average of 42.2 hours per week.
The U.S. Department of Health and Human Services
responded to this need by conducting a comprehensive Gender
survey of the nursing workforce every 4 years, begin- Nursing remains a profession dominated by women;
ning in 1977. Known as the National Sample Survey of however, the percentage of men in nursing increased by
Registered Nurses (NSSRN), this effort gave policymak- 50% between 2000 and 2008 (U.S. Department of Health
ers, educators, and other nurse leaders data about the and Human Services, 2010). Among NCSBN/FSNWC
workforce, allowing them to make informed decisions 2015 survey respondents, 8% were men compared with
about allocation of resources, development of programs, 7% in the 2013 survey. In 2014 men comprised 15% of
and recruitment of nurses. The final NSSRN was con- students in entry-level bachelor of science in nursing
ducted in 2008, and results were published in 2010. The (BSN) programs (National League for Nursing [NLN],
federal government has since discontinued this very 2014). According to the AACN (2015a), data obtained
CHAPTER 1 Nursing in Today’s Evolving Health Care Environment 3
from nurses in practice showed that male and female This stabilization of the aging pattern seen in the final
RNs were equally likely to have a bachelor’s or higher NSSRN survey is an optimistic sign that nursing is seen
degree in nursing or nursing-related fields (49.9% and as an option for younger people entering the workforce
50.3%, respectively). Men, however, were more likely and that nursing will not face a shortage as older nurses
than women to have a bachelor’s or higher degree in age out of the workforce in a few years. However, with
nursing and any nonnursing field (62% vs. 55%). A approximately one-third of the current nursing work-
higher percentage of the men work in hospitals (76% vs. force older than age 50 (Health Resources and Services
62%). At 41%, men are overrepresented in the advanced Administration, 2013), the profession of nursing must
practice role of certified registered nurse anesthetists. continue to recruit and educate younger nurses to pre-
Among all other job titles held by men, staff nurse and vent a nursing shortage as older nurses move toward
administration have proportional representation, with retirement.
about 7% of these positions held by men. Nurse prac-
titioners and positions designated as “other” (e.g., con- Race and Ethnicity
sultant, clinical nurse leader, informatics, researcher) are Racial and ethnic minorities comprise 37% of the U.S.
slightly less proportional, with 6% of these positions held population today but only 19% of the RN population,
by men. Men hold only about 3.8% of faculty positions. an underrepresentation by about 50% in 2013 (Budden
et al., 2013). This is similar to the findings in 2008 in
Age the NSSRN (Fig. 1.1). Although troublesome, the num-
The future of any profession depends on the infusion of ber is an improvement from 2004, when only 12.2% of
youth, and the steady increase in the age of the nurs- RNs had racial/ethnic minority backgrounds. Detailed
ing workforce has been a concern. Earlier data indicated data from the NSSRN showed that the largest dispar-
that the rate of aging has slowed in the nursing work- ity between the U.S. general population and the RN
force as a result of the increased number of working RNs population is seen with Hispanics/Latinos of any race.
younger than age 30, which offsets the increasing num- Although this group forms about 15.4% of the U.S. pop-
ber of nurses aged 60 or older who continue to work ulation, they make up only 3.6% of RNs. Black/African
(U.S. Department of Health and Human Services, 2010). American, non-Hispanics also have a significant dis-
The rise in the number of nurses younger than age 30 parity; now constituting 12.2% of the U.S. population,
is attributed to the increased number of BSN graduates, this group makes up just 5.4% of RNs. The only group
who tend to be younger than graduates from other types that exceeds its representational percentage in the gen-
of nursing programs. Since 2005, the average age of eral population is the Asian or Native Hawaiian/Pacific
graduates from all nursing programs has been 31 years Islander, non-Hispanic group. Comprising 4.5% of the
old. BSN graduates, at an average age of 28 years old, are general population, this group makes up 5.8% of the RN
5 years younger than graduates of associate degree and population, possibly because a substantial number of
diploma (hospital-based) programs, who are on average RNs practicing in the United States received their nurs-
33 years old. ing education in India or the Philippines, thus contrib-
The median age is that point at which half of the uting to their overrepresentation (U.S. Department of
nurses are older and half are younger, and it provides a Health and Human Services, 2010). In 2014 a biennial
more useful metric of the workforce than does calculat- survey of nursing schools by the NLN demonstrated
ing a mean age. Since 1988, when the median age was promise that the diversity of the profession is improv-
38, the median age of nurses rose by 2 years between ing. In 1995 fewer than 18% of students enrolled in a
each survey, so that by 2004, the median age was 46, a professional nursing program were from underrepre-
worrisome figure that meant the nursing workforce was sented racial or ethnic minority groups, in contrast to
continuing to age. The increasing number of nurses aged more than 35% in 2014 (NLN, 2014).
60 and older who are still in the workforce may reflect Despite efforts to recruit and retain racial/ethnic
economic conditions requiring older nurses to remain minority women and men to the profession, nursing
employed rather than retiring. Nursing is reasonably still has a long way to go before the racial/ethnic compo-
protected from the layoffs and downsizing experienced sition of the profession more accurately reflects that of
in other professions. the United States as a whole. This situation is improving,
American Indian/
0.3%
Alaska Native,
0.8%
non-Hispanic
Non-Hispanic, 1.7%
2 or more races 1.5%
Asian or Native Hawaiian/
5.8%
Pacific Islander,
4.5%
non-Hispanic
Black/African American, 5.4%
non-Hispanic 12.2%
Hispanic/Latino, 3.6%
any race 15.4%
83.2%
White, non-Hispanic 65.6%
Percentages
RN Population
U.S. Population
Fig. 1.1 Registered nurse (RN) and U.S. populations by race/ethnicity, 2008. The proportion of nurses who
are White, non-Hispanic is greater than their proportion in the U.S. population. (Data from U.S. Department
of Health and Human Services, Health Resources and Services Administration: The Registered Nurse Pop-
ulation: Findings from the 2008 National Sample Survey of Registered Nurses, Washington, DC, 2010, U.S.
Government Printing Office, p. 7-7.)
however. In a recent report on enrollment and gradua- associate degree in nursing (ADN); and (3) a diploma
tion in bachelor’s and graduate programs in nursing, the in nursing, awarded after the successful completion of
AACN (2015a) found that 30.1% of nursing students in a hospital-based program that typically takes 3 years to
entry-level BSN programs were from underrepresented complete, including prerequisite courses that may be
backgrounds. taken at another school.
According to the National League for Nursing
Education (NLN), the number of diploma programs educated only
The basic education to become a nurse is referred to as 3% to 4% of all new RNs in between 2003 and 2014
the entry level into practice. Successful completion of (NLN, 2014) as nursing education has shifted to colleges
your basic education, however, does not qualify you to and universities (AACN, 2011). The majority of nurses
become a nurse. Once you have graduated from a school (53%) in the United States get their initial nursing edu-
of nursing approved by your state, you are qualified to cation in ADN programs (RWJF, 2013); in the NCSBN/
take the National Council Licensure Examination for FSNWC (2013) survey, 39% of the 41,823 respondents
Registered Nurses, known as the NCLEX-RN®. Once reported having an ADN as their first degree or creden-
you have passed the NCLEX-RN®, you can be licensed tial, and 36% reported having a BSN as their first degree
as an RN if you meet other requirements by your state or credential.
board of nursing, such as passing a background check. Many ADN-prepared RNs eventually return to school
Nursing has three mechanisms by which you can to complete a BSN degree. Between 2004 and 2012, the
get basic nursing education to qualify to take the number of RNs enrolled in BSN programs almost tri-
NCLEX®: (1) a 4-year education at a college or univer- pled, from 35,000 to slightly fewer than 105,000 (RWJF,
sity conferring a BSN degree; (2) a 2-year education at 2013). Currently, approximately 55% of RNs have BSN
a community college or technical school conferring an or higher degrees (Health Resources and Services
Administration, 2013). Many colleges and universities Practice Settings for Professional Nurses
offer BSN programs, often online, to accommodate RNs As members of the largest health care profession in
in practice who want to work toward a BSN degree as the United States, nurses practice in a wide variety of
a supplement to their basic nursing education at the settings. The most common setting is the hospital, and
ADN or diploma level. Nursing education is discussed many new nurses seek employment there to strengthen
in greater detail in Chapter 4. their clinical and assessment skills. Nurses practice in
Globalization and the international migration of clinics, community-based facilities, medical offices,
nurses have increased internationally educated nurses skilled nursing facilities (SNFs), and other long-term
(IENs) practicing in the United States by 40% between settings. Nurses also provide care in places where peo-
2006 and 2015, and in 2016 approximately 15% of all ple spend much of their time: homes, schools, and
RNs in the United States were educated in other coun- workplaces. In communities, nurses work in the mili-
tries (World Education Service, 2018). The recruitment tary, community and senior centers, children’s camps,
of IENs to the United States has been a strategy to expand homeless shelters, and, recently, in retail clinics found
the nursing workforce in response to the recent nursing in some pharmacies. Nurses also provide palliative care
shortage. This strategy, however, may result in nursing (i.e., symptom management to improve quality of life)
shortages in their own countries. IENs face challenges and end-of-life care, often in the homes of patients who
as they join the workforce in the United States, includ- are terminally ill or in inpatient hospice homes or facil-
ing English as a second language and problems with ities. Increasingly, nurses with advanced degrees, train-
their peers who may not perceive them as knowledge- ing, and certification are working in their own private
able (Thekdi et al., 2011). Deep cultural differences may practices or in partnership with physicians or other
further separate the IENs from their American peers. providers. This expansion of practice holds promise for
Thekdi and colleagues (2011) noted that IENs might nurses to widen their roles in health care, especially as
have views of gender, authority, power, and age that vary the American health care system continues to evolve.
from those of Americans, and which may affect their Hospitals remained the primary work site for RNs,
communication styles. with 63.2% of nurses employed by hospitals in either
Sigma Theta Tau International (STTI) published inpatient or outpatient settings, an increase of 25% in
a position paper on international nurse migration. the past decade (Health Resources and Services Admin-
Although this paper was published in 2005, it reflects istration, 2013). Most of these nurses (39.6%) work in
STTI’s current, ongoing position regarding international inpatient units in community hospitals, whereas others
nurse migration (STTI, 2005). STTI recognizes the work in specialty hospitals, long-term care hospitals,
autonomy of nurses in making decisions for themselves and psychiatric units. The federal government employs
about where to live and work, noting that “push/pull” nurses, generally in the U.S. Department of Veterans
factors shape nurse migration. Push factors include poor Affairs (VA) hospitals, where 1.1% of RNs work.
compensation and working conditions, political insta- Ambulatory care settings, such as nurse-based prac-
bility, and lack of opportunities for career development tices, physician-based practices, and free-standing emer-
that drive (push) a nurse to seek employment in another gency and surgical centers, accounted for 10.5%, the
country. Factors that pull nurses to emigrate include second largest segment of the nurse workforce. Public
opportunities for a better quality of life, personal safety, and community health accounted for 7.8% of employed
and professional incentives such as increased pay, bet- nurses, and an additional 6.4% worked in home health.
ter working conditions, and career development. STTI Skilled nursing facilities (SNFs), or extended care facil-
calls for further exploration of the issue with a focus on ities, employed 5.3% of nurses in the workforce. The
identifying “solutions that do not promote one nation’s remainder of employed RNs worked in settings such as
health at the expense of another’s” (p. 2). Furthermore, schools of nursing; nursing associations; local, state, or
STTI endorsed the International Council of Nurses federal governmental agencies; state boards of nursing;
position in calling for a regulated recruitment process or insurance companies (U.S. Department of Health and
based on ethical principles that deter exploitation of Human Services, 2010, pp. 3–9).
foreign-educated nurses and reinforce sound employ- Not all nurses provide direct patient care as their pri-
ment policies (p. 4). mary role. A small but important group of nurses spend
the majority of their time conducting research, teaching Health care reform and the push to transform the
undergraduate and graduate students in the classroom health care system are moving nurses into new territory.
and in clinical settings, managing companies as chief Numerous new opportunities and roles are being devel-
executives, and consulting with health care organiza- oped that use nurses’ skills in innovative and exciting
tions. Nurses with advanced levels of education, such as ways. In the following section, you will be introduced to
master’s and doctoral degrees, are prepared to become a range of settings in which nurses practice. These areas
researchers, educators, and administrators. Nurses can are only a sample of the growing variety of opportunities
practice as advanced practice nurses (APNs), including available to nurses entering practice today.
a variety of types of nurse practitioners (NPs), clini-
cal nurse specialists (CNSs), certified nurse-midwives Nursing in Hospitals
(CNMs), and certified registered nurse anesthetists Nursing care originated and was practiced informally in
(CRNAs). These advanced practice roles are described home and community settings and moved into hospi-
later in this chapter. tals only within the past 150 years. Hospitals vary widely
Nurses have much to consider in deciding where to in size and services. Certain hospitals are referred to as
practice. Some settings will not be immediately open to medical centers and offer comprehensive specialty ser-
new nurses because they require additional educational vices, such as cancer centers, maternal-fetal medicine
preparation or work experience. Importantly, nurses services, and heart centers. Medical centers are usually
entering the workforce need to consider their special tal- associated with university medical schools and have a
ents, likes, and dislikes—neither the nurse nor patients complex array of providers. Medical centers can have
benefit when a nurse is working with a population for 1000 or more beds and have a huge nursing workforce.
which he or she has little affinity. A nurse who enjoys Medical centers are often designated as level 1 trauma
working with children may not feel at ease in caring for centers because they offer highly specialized surgical and
elderly patients; on the other hand, a nurse who loves supportive care for the most severely injured patients.
children may find that caring for sick children is emo- The patients at community-based hospitals usually are
tionally stressful. A nurse with excellent communication less severely ill than those needing comprehensive care
skills may find that a postanesthesia care unit (PACU) or trauma care at a medical center. However, if a patient
does not allow the formation of professional relation- becomes unstable or if the patient’s condition warrants,
ships with patients that this nurse might appreciate in a he or she can be transported to a larger hospital or a
psychiatric setting. Nursing school offers the chance to medical center. Nurses play an important role in identi-
experience a wide variety of settings with diverse patient fying very ill patients, assisting in stabilizing their con-
populations. At the end of your studies, you may be sur- ditions, and preparing them for transport.
prised by the skills you have developed and populations In general, nurses in hospitals care for patients who
that appeal to you (Fig. 1.2). have medical or surgical conditions (e.g., those with
cancer or diabetes, those in need of postoperative care),
children and their families on pediatric units, women
and their newborns, and patients who have had severe
trauma or burns. Specialty areas are referred to as “units,”
such as operating suites or emergency departments,
intensive care units (e.g., cardiac, neurology, medical),
and step-down or progressive care units, among others.
In addition to providing direct patient care, nurses are
educators, managers, and administrators who teach or
supervise others and establish the direction of nursing
on a hospital-wide basis.
Various generalist and specialist certification oppor-
tunities are appropriate for hospital-based nurses,
Fig. 1.2 Although most nurses work in hospitals, nurses in
including medical-surgical nursing, pediatric nursing,
home health settings often enjoy long-term relationships with pain management nursing, informatics nursing, genetics
their patients. (Photo used with permission from iStockphoto.) nursing–advanced, psychiatric–mental health nursing,
nursing executive, nursing executive–advanced, hemo- becoming administrators or managers was often neces-
stasis nursing, and cardiovascular nursing, among sary for nurses to be promoted or receive salary increases,
others. Certification means that nurses have demon- which removed them from bedside care. Today, in hos-
strated their expertise in a particular area of care and pitals with clinical ladder programs, nurses no longer
have passed rigorous credentialing testing offered by the must make that choice; clinical ladder programs allow
American Nurses Credentialing Center (ANCC), one of nurses to progress professionally while staying in direct
three entities comprising the ANA Enterprise. No other patient care roles.
health care facility offers such variety of opportunities At the top of most clinical ladders are clinical
for practice as hospitals offer. nurse specialists (CNS), who are APNs with master’s,
The educational credentials required of RNs practic- post-master’s, or doctoral degrees in specialized areas
ing in hospitals can range from associate degrees and of nursing, such as oncology (cancer) or diabetes care.
diplomas to doctoral degrees. In general, entry-level The CNS role varies but generally includes responsibil-
positions require only RN licensure. Many hospitals ity for serving as a clinical mentor and role model for
require nurses to hold bachelor’s degrees to advance other nurses, as well as setting standards for nursing
on the clinical ladder or to assume management posi- care on one or more particular units. The oncology clin-
tions. A clinical ladder is a multiple-step program that ical specialist, for example, works with the nurses on the
begins with entry-level staff nurse positions. As nurses oncology unit to help them stay informed regarding the
gain experience, participate in continuing education latest research and skills useful in the care of patients
(CE), demonstrate clinical competence, pursue formal with cancer. The clinical specialist is a resource person
education, and become certified, they become eligible for the unit and may provide direct care to patients or
to move up the clinical ladder. There is no single model families with particularly difficult or complex problems,
for clinical advancement for nurses across hospitals establish nursing protocols, and ensure that nursing
and other health care agencies. When exploring work practice on the unit is evidence based. Evidence-based
settings, nurses as prospective employees should ask practice (EBP) refers to nursing care that is based on the
about the clinical ladder and opportunities for career best available research evidence, clinical expertise, and
advancement. patient preference. More details about EBP are found in
Most new nurses choose to work in hospitals as Chapter 10.
staff nurses initially to gain experience in organizing Salaries and responsibilities increase at the upper
and delivering care to multiple patients. For many, staff levels of the clinical ladder. The clinical ladder concept
nursing is extremely gratifying, and nurses continue in benefits nurses by allowing them to advance while still
this role across their careers. Others pursue additional working directly with patients. Hospitals also benefit by
education, sometimes provided by the hospital, to work retaining experienced clinical nurses in direct patient
in specialty units such as neonatal intensive care or car- care, thus improving the quality of nursing care through-
diac care. Although specialty units often require clinical out the hospital. Research has demonstrated that patient
experience and additional training, some hospitals allow outcomes are more positive for patients cared for by RNs
new graduates to work in these units. with a bachelor’s or higher degree. Linda Aiken, PhD, RN,
Some nurses find that management is their strength. FAAN, is a leader in nursing who has conducted import-
Nurse managers are in charge of all activities on ant research documenting the positive impact of adequate
their units, including patient care, continuous quality RN staffing on patient outcomes. More than a decade ago,
improvement (CQI), personnel hiring and evaluation, Aiken and colleagues (2003) published a groundbreaking
and resource management, including the unit budget. study in which they found that patients on surgical units
Being a nurse manager in a hospital today requires busi- with more BSN-prepared nurses had fewer complications
ness acumen and knowledge of business and financial than patients on units with fewer BSN nurses. Aiken has
principles to be most effective in this role. Nurse man- published widely on nurse staffing and safety since pub-
agers typically assume 24-hour accountability for the lishing this landmark study. In 2010 Aiken and colleagues
units they manage and are often required to have earned reported on a comparison of nurse and patient outcomes
a master’s degree. among hospitals in California, which has state-mandated
Most nurses in hospitals provide direct patient care, nurse-to-patient ratios, and in Pennsylvania and New Jer-
sometimes referred to as bedside nursing. In the past, sey, neither of which has state-mandated nurse-to-patient
ratios. Furthermore, concern about patient quality and is associated with significantly fewer deaths after sur-
safety is an international issue. In 2012 Aiken and col- gery: Every 10% increase in baccalaureate-prepared
leagues led a very large team in examining nurse and nurses is associated with a 7% reduction in mortality. See
patient satisfaction, hospital environments, quality of Evidence-Based Practice Box 1.1 for a description of these
care, and patient safety across 12 European countries and landmark studies.
the United States. Again in 2014, Aiken et al. conducted Rigid work scheduling was one of the greatest draw-
a retrospective observational study of nine European backs to hospital nursing in the past. These schedules usu-
countries analyzing 422,730 patient records. They found ally included evenings, nights, weekends, and holidays.
the proportion of nurses with a baccalaureate education Although hospital units must be staffed around the clock,
EVIDENCE-BASED PRACTICE BOX 1.1

The Evidence: Better Professional Nurse Staffing Improves Quality and Safety of Patient Care
Linda Aiken, PhD, RN, FAAN, Professor of Nursing and Pro- phasis in national nurse workforce planning on policies to
fessor of Sociology at the University of Pennsylvania School alter the educational composition of the future nurse work-
of Nursing, is the director of the Center for Health Outcomes force toward a greater proportion with bachelor’s or higher
and Policy Research. She is an authority on causes, conse- education as well as ensuring the adequacy of the overall
quences, and solutions for nursing shortages both in the supply” (p. 1623). They concluded that improved public
United States and worldwide. Dr. Aiken has published ex- financing of nursing education and increased employers’
tensively. She and her colleagues noted growing evidence efforts to recruit and retain highly prepared bedside nurses
suggesting “that nurse staffing affects the quality of care in could lead to substantial improvements in quality of care.
hospitals, but little is known about whether the educational More recently, California became the first state to en-
composition of registered nurses (RNs) in hospitals is relat- force state-mandated minimum nurse-to-patient ratios.
ed to patient outcomes” (Aiken et al., 2003). They wondered Much commentary about the pros and cons of these types
whether the proportion of a hospital’s staff of bachelor’s or of mandates has been generated. To determine whether
higher degree–prepared RNs contributed to improved pa- nurse and patient outcomes were different in California
tient outcomes. To answer this question, they undertook a than in two states without mandated staffing, Aiken and
large analysis of outcome data for 232,342 general, ortho- colleagues (2010) analyzed survey data from 22,336 hos-
pedic, and vascular surgery patients discharged from 168 pital staff nurses in California, Pennsylvania, and New Jer-
Pennsylvania hospitals over a 19-month period. They used sey, as well as state hospital discharge databases. From
statistical methods to control for risk factors such as age, this highly complex analysis they determined the following:
gender, emergency or routine surgeries, type of surgery,
When we use the predicted probabilities of dying
preexisting conditions, surgeon qualifications, size of hospi-
from our adjusted models to estimate how many
tal, and other factors. Their findings were very important:
fewer deaths would have occurred in New Jersey
To our knowledge, this study provides the first empirical
and Pennsylvania hospitals if the average patient-to-
evidence that hospitals’ employment of nurses with BSN
nurse ratios in those hospitals had been equivalent to
and higher degrees is associated with improved patient out-
the average ratio across the California hospitals, we
comes. Our findings indicate that surgical patients cared for
get 13.9% (222/1598) fewer surgical deaths in New
in hospitals in which higher proportions of direct-care RNs
Jersey and 10.6% (264/2479) fewer surgical deaths
held bachelor’s degrees experienced a substantial survival
in Pennsylvania (p. 917).
advantage over those treated in hospitals in which fewer
staff nurses had BSN [bachelor of science in nursing] or In addition, the nurses in California experienced lower lev-
higher degrees. Similarly, surgical patients experiencing se- els of burnout (a condition associated with intense and pro-
rious complications during hospitalization were significantly longed stress in work settings) and were less likely to report
more likely to survive in hospitals with a higher proportion being dissatisfied with their jobs. These important findings
of nurses with baccalaureate education (p. 1621). can inform ongoing debates in other states regarding legis-
Noting that fewer than half of all hospital staff nurses na- lation regulating nurse-patient ratio or mandatory reporting
tionally are prepared at the bachelor’s or higher level, and of nurse staffing. Aiken and colleagues (2010) concluded,
citing a shortage of nurses as a complicating factor, this “Improved nurse staffing, however it is achieved, is associ-
group of researchers recommended “placing greater em- ated with better outcomes for nurses and patients” (p. 918).
EVIDENCE-BASED PRACTICE BOX 1.1—cont’d

The Evidence: Better Professional Nurse Staffing Improves Quality and Safety of Patient Care
Quality and safety of patient care are of international con- by 7%. In other words, cutting nurse staff to reduce the
cern. In 2012 Aiken and a team of researchers from the Unit- nursing budget may adversely affect patient outcomes.
ed States and Europe published findings from a very large, Also, increasing the number of baccalaureate-prepared
cross-sectional study of 488 general acute care hospitals in nurses may prevent hospital deaths.
12 European countries and 617 similar hospitals in the Unit- In 2018 New York became the first state to require
ed States. Despite deficits in the quality of care present in that new RNs obtain their baccalaureate degree within
all countries, Aiken and colleagues found that hospitals pro- 10 years of graduation. Much of the evidence present-
viding good work environments and better staffing by pro- ed to back this legislative bill came from the pivotal work
fessional nurses had nurses and patients who were more done by Aiken and colleagues. The bill is located here:
satisfied with care. Furthermore, their findings suggested https://www.nysenate.gov/legislation/bills/2017/s6768.
that good work environments and better professional nurse
staffing resulted in improving quality and safety of care. The Resources
Aiken LH, Clarke SP, Cheung RB, Sloane D, Silber JH: Ed-
implication of these findings is that improvement of hospital
ucational levels of hospital nurses and surgical patient
work environments could be an affordable strategy to im- mortality, Journal of the American Medical Association
prove both patient outcomes and retention of professional 290(12):1617–1623, 2003.
nurses who provide high-quality care. Aiken LH, Sermeus W, Van den Heede K, Sloane DM, Busse
In 2014 Aiken et al. published seminal research assess- R, McKee M, Kutney-Lee A: Patient safety, satisfaction,
ing the impact of nursing patient ratios and educational and quality of hospital care: cross sectional survey of
qualifications in 300 hospitals in nine European countries. nurses and patients in 12 countries in Europe and the
They reviewed more than 422,730 patient records of pa- United States, British Medical Journal 344:1717, 2012.
tients who underwent common surgeries and surveyed Aiken LH, Sloane DM, Bruyneel L, Van den Heede K,
26,516 nurses practicing in the study hospitals to gather Griffiths P, Busse R, Sermeu W: Nurse staffing and
education and the hospital mortiality in nine European
data on nurse staffing and education. The researchers
countries: a retrospective observational study, Lancet
identified that an increase of 10% of nurses holding a 383(9931):1824–1830, 2014.
baccalaureate degree in the hospital setting is associated Aiken LH, Sloane DM, Cimiotti JP, Clarke SP, Flynn L,
with a 7% reduction in mortality. Also, an increase of a Seago JA, Spetz J, Smith HK: Implications of the Cali-
nurse’s patient load by one patient increased the likeli- fornia nurse staffing mandate for other states, Health
hood of an inpatient dying within 30 days of admission Services Research 45(4):904–921, 2010.
flexible staffing is more common now, a process by which

But I appreciate the technical challenges of providing
nurses on a particular unit negotiate with one another and
care for an infant born very prematurely or that has
establish their own schedules to meet personal and family
a serious congenital condition. The biggest challenge
responsibilities while ensuring that appropriate staffing
for me though is working with a full-term baby that
for high-quality patient care is provided. Staffing needs
had some kind of unexpected trauma at birth. These
may be predictable, such as in the emergency department
babies can be very, very sick, and their parents need a
or surgical units when times of high use can be antic-
lot of support and information. I take care of my little
ipated. Accordingly, some units may decrease staffing
patients the same way I would want someone to take
over major holidays because numbers of admissions are
care of my own child. I can only imagine how terri-
known to be low during certain days of the year when
fying it is for the parents for their baby to be so sick. I
elective procedures are not routinely scheduled.
know that some of the procedures that I have to do are
Each hospital nursing role has its own unique char-
painful, so I make sure that I talk to a baby while I am
acteristics. In the following profile, an RN discusses his
doing a procedure and try to provide comfort the best I
role as a nurse in a neonatal intensive care unit (NICU):
can. Sometimes, when it is possible, I’ll wrap a baby in
Many people are surprised when I tell them that I work a blanket and rock him or her for a while when things
in a NICU. They don’t seem to expect that a man might are quiet in the unit. The only thing better than that is
enjoy working with the tiniest patients in the hospital. the day the parents take the baby home.
When the “fit” between nurses and their role Nursing in Communities
requirements is good, being a nurse is particularly Lillian Wald (1867–1940) is credited with initiating com-
gratifying, as an oncology nurse demonstrates in dis- munity health nursing when she established the Henry
cussing her role: Street Settlement in New York City in 1895. Commu-
Being an oncology nurse and working with people nity health nursing today is a broad field, encompassing
with cancer that may shorten their lives brings you areas formerly known as public health nursing. Com-
close to patients and their families. The family room munity health nurses work in ambulatory clinics, health
for our patients and their families is much like some- departments, hospices, homes, and a variety of other
one’s home. Families bring in food and have dinner community-based settings.
with their loved one right here. Working with termi- Community health nurses may work for either the
nally ill patients is a tall order. I look for ways to help government or private agencies. Those working for pub-
families determine what they hope for as their loved lic health departments provide care in clinics, schools,
one nears the end of life. It varies. Sometimes they retirement communities, and other community settings.
hope for a peaceful death, or hope to make amends They focus on improving the overall health of commu-
with an estranged family member or friend or hope nities by planning and implementing health programs,
to go to a favorite place one more time. The diagno- as well as delivering care for individuals with chronic
sis of cancer is traumatic, and patients may struggle health problems. Community health nurses provide
to cope, especially if their cancer is very advanced or educational programs in health maintenance, disease
untreatable. I love getting to know my patients and prevention, nutrition, and child care, among others.
their families and feel that I can be helpful to them They conduct immunization clinics and health screen-
as they face death, sometimes by simply being with ings and work with teachers, parents, physicians, and
them. They cry, I cry—it is part of nursing for me, community leaders toward a healthier community.
and I would have it no other way. Many health departments also have a home health com-
ponent. Over the past several decades an increasing num-
These are only two of the many possible roles nurses ber of public and private agencies provides home health
in hospital settings may choose. Although brief, these services, a form of community health nursing. In fact, home
descriptions convey the flavor of the responsibility, com- health care is a growing segment of the health care industry.
plexity, and fulfillment to be found in hospital-based Home health care is a natural fit for nursing. Home
nursing (Fig. 1.3). health nurses across the United States provide quality
care in the most cost-effective and, for patients, most
comfortable setting possible. Patients cared for at home
may face significant health challenges because of man-
agement of chronic illnesses or early hospital discharges
in efforts to control costs. As a result, technological
devices such as ventilators and intravenous pumps, and
significant interventions such as administration of che-
motherapy and total parenteral nutrition, are encoun-
tered in home health care. Wound care is another
domain of home health nursing. Wounds managed in the
patient’s home can be extensive, and home health nurses
providing wound care can assess the patient’s home envi-
ronment for factors that help or hinder healing.
Home health nurses must possess up-to-date nurs-
ing knowledge and be secure in their own nursing skills
because they do not have the expertise of more experi-
Fig. 1.3 Hospital staff nurses work closely with the families of
enced nurses quickly available, as they would have in a
patients, as well as with the patients themselves. (Photo used hospital setting. Strong assessment and communication
with permission from Photos.com.) skills are essential in home health nursing. These nurses
must make independent judgments and be able to recog- office practices supervise other care providers, such as
nize patients’ and families’ learning needs. Home health licensed practical/vocational nurses, nurse aides, and,
nurses must also recognize the limits of their education depending on the size of the practice, other employees
and experience and seek help when the patient’s needs of the practice such as assistants who schedule patient
are beyond the scope of their abilities. An RN working appointments and manage patient records.
in home health care relates her experience: An RN who works for a nephrology practice with
three nephrologists describes a typical day:
I have always found home care to be very rewarding.
I get to know patients in a way I could never have if I I first make rounds independently on patients in the
had continued to work in a hospital. One of my favor- dialysis center, making sure they are tolerating the dial-
ite success stories involved a man with a long history ysis procedure and answering questions about their
of osteomyelitis—an infection in the bone—resulting treatments and diets. I then make rounds with one of
from a car wreck 18 years earlier. He had a new cen- the physicians in the hospital as she visits patients and
tral line and was going to get 6 months of intravenous prescribes new treatments. The afternoon is spent in
antibiotics. If this treatment didn’t work, he was fac- the office assessing patients as they come for their phy-
ing an above-the-knee amputation. I taught his wife sician’s visit. I might draw blood for a diagnostic test
how to assess the dressing and site, how to change the on one patient and do patient teaching regarding diet
dressing, and how to infuse the antibiotics twice a day. with another. No two days are alike, and that is what I
At my once-a-week visits to draw blood, I counseled love about this position. I have a sense of independence
the patient about losing weight and quitting smoking but still have daily patient contact.
because these measures would help in his healing. He
RNs considering employment in office settings need
lost 80 pounds, quit smoking completely, and at the end
good communication skills because many of their respon-
of 6 months, he had no signs of infection. He described
sibilities involve communicating with patients, families,
himself as “a new man.” I was so happy for him and
employers, pharmacists, and hospital admissions offices.
his wife. Holistic nursing care in his own home made a
Nurses should be careful to ask prospective employers the
huge difference for the rest of his life.
specifics of the position because nursing roles in office prac-
Some nurses are certified as community health or tices can range from routine tasks to challenging responsi-
home health nurses by the ANCC. The examinations for bilities requiring expertise in a particular practice setting,
these two specialties have now been retired, but nurses such as that described by the nurse in the nephrology prac-
certified before this can have their credentials renewed. tice. Educational requirements, hours of work, and specific
The ANCC does have an examination for certification as responsibilities vary, depending on the preferences of the
a public health nurse–advanced. The demand for nurses employer. Some nurses find a predictable daily sched-
to work in a variety of community settings is expected ule with weekends and holidays off to be an advantage in
to continue to increase as care moves from hospitals to working in an office practice. An important advantage of
homes and other community sites. employment in an office setting is that over time, nurses get
to know their patients well, including several members of a
Nursing in Medical Offices family, depending on the type of practice.
Nurses who are employed in medical office settings
work in collaboration with physicians, NPs, and their Nursing in the Workplace
patients. Office-based nursing activities include per- Many companies today employ occupational and envi-
forming health assessments, reviewing medications, ronmental health nurses to provide basic health care
drawing blood, giving immunizations, administering services, health education, screenings, and emergency
medications, and providing health teaching. Nurses in treatment to employees in the workplace. Corporate
office settings also act as liaisons between patients and executives have long known that good employee health
physicians or NPs. They expand on and clarify recom- reduces absenteeism, insurance costs, and worker errors,
mendations for patients, as well as provide emotional thereby improving company profitability. Occupational
support to anxious patients. They may visit hospital- health nurses (OHNs) represent an important investment
ized patients, and some assist in surgery. Often, RNs in by companies in the health and safety of their employees.
They are often asked to serve as consultants on health available through the American Board for Occupational
matters within the company. OHNs may participate in Health Nurses (ABOHN).
health-related decisions, such as policies affecting health
insurance benefits, family leaves, and acquisition and Nursing in the Armed Services
placement of automatic external defibrillators. Depend- Nurses practice in both peacetime and wartime settings
ing on the size of the company, the OHN may be the only in the armed services. Nurses serving in the military
health professional employed in a company and there- (“military nurses”) may serve on active duty or in mili-
fore may have a good deal of autonomy. tary reserve units, which means that they will be called
Being licensed is generally the minimum require- to duty in the case of an emergency. They serve as staff
ment for nurses in occupational health roles. The nurses and supervisors in all major medical specialties.
American Association of Occupational Health Nurses Both general and advanced practice opportunities are
(AAOHN) recommends that OHNs have a bachelor’s available in military nursing, and the settings in which
degree. OHNs must possess knowledge and skills that these nurses practice use state-of-the-art technology.
enable them to perform routine physical assessments Military nurses often find themselves with broader
(e.g., vision and hearing screenings) for all employees. responsibilities and scope of practice than do civilian
Good interpersonal skills to provide counseling and nurses because of the demands of nursing in the field, on
referrals for lifestyle problems, such as stress or sub- aircraft, or onboard ship. Previous critical care, surgery,
stance abuse, are a bonus for these nurses. At a mini- or trauma care experience is desirable but not required.
mum, they must know first aid and basic life support. Military nurses are required to have a BSN degree for
If employed in a heavy industrial setting where the risk active duty. They enter active duty as officers and must
of burns or trauma is present, OHNs must have special be between the ages of 21 and 46½ years when they
training to manage those types of medical emergencies. begin active duty. Professional Profile Box 1.1 is a profile
OHNs also have responsibilities for identifying of the work of Lt. Joseph Biddix, BSN, RN, a nurse in the
health risks in the entire work environment. They must Navy who was stationed on a hospital ship.
be able to assess the environment for potential safety A major benefit of military nursing is the opportu-
hazards and work with management to eliminate or nity for advanced education. Military nurses are encour-
reduce them. They need in-depth knowledge of govern- aged to seek advanced degrees, and support is provided
mental regulations, such as those of the Occupational during schooling. The U.S. Department of Defense
Safety and Health Administration (OSHA) and must pays for tuition, books, moving expenses, and even sal-
ensure the company complies. They may instruct new ary for nurses obtaining advanced degrees. This allows
workers in the effective use of protective devices such the student to focus on his or her studies. Nurses with
as safety glasses and noise-canceling earphones. OHNs advanced degrees are eligible for promotion in rank at
also understand workers’ compensation regulations and an accelerated pace.
coordinate the care of injured workers with the facilities Travel and change are integral to military nursing,
and providers who provide care for an employee with a so these nurses must be flexible. Military nurses in the
work-related injury. Some injuries may be life threaten- reserves must be committed to readiness; they must be
ing; others may be chronic but clearly related to work, ready to go at a moment’s notice. All military nurses
such as musculoskeletal injuries from repetitive motion may be called on for active wartime duty anywhere in
or poorly designed workspaces. the world.
Nurses in occupational settings have to be confi- In 2011 Lieutenant General (Lt. Gen.) Patricia Horoho
dent in their nursing skills, be effective communicators was nominated and confirmed to become the Army Sur-
with both employees and managers, be able to motivate geon General, the first nurse and the first woman to serve
employees to adopt healthier habits, and be able to func- in this capacity. Horoho had previously commanded the
tion independently in providing care. The AAOHN is Walter Reed Health Care System and was serving in the
the professional organization for OHNs. The AAOHN Pentagon on September 11, 2001, where she cared for
provides conferences, webcasts, a newsletter, a jour- the wounded after terrorists crashed a plane into the
nal, and other resources to help OHNs stay up-to-date building. Lt. Gen. Horoho is an experienced clinical
(website: www.aaohn.org). Certification for OHNs is trauma nurse (National Journal, 2011).
PROFESSIONAL PROFILE BOX 1.1 MILITARY NURSE

My nursing path was untraditional. I graduated from col- their faces light up when they “get it.” Whether we’re
lege in 2005 with an Arts degree in Media Studies and discussing the physiology of hypertension or how to treat
Production and immediately began an internship with the for shock after a blast injury, you know when the light-
entertainment industry in Los Angeles. I eventually worked bulb turns on and your sailor has added another layer to
for a top talent management firm, yet after 4 successful his or her knowledge base.
years in the business, something was missing. I kept ask- Earlier in my career, I was stationed aboard the USNS
ing myself, “Why doesn’t this feel more rewarding?” Comfort (T-AH 20) hospital ship for 6 months in support of
I began exploring other options in search of professional Continuing Promise 2015. This mission allowed me to pro-
gratification, and the idea of military service kept popping vide humanitarian assistance alongside partner nation and
into my head. I questioned what the military would do civilian experts to patients in 11 countries in Central and
with a film major whose only job experience was working South America and the Caribbean. As a Navy nurse, I spent
in Hollywood. While deciding options, a close friend told 10 days in Belize providing nursing care and education to
me that he was planning to return to school for a second- patients and helped provide nursing assistance to our Sea-
degree nursing program. It didn’t sound like a bad idea bees construction crew while painting buildings in Panama.
and this would be a perfect career for the military. My In between providing care to thousands of patients in oth-
internal wheels were spinning, so I called my mom for ad- er nations, I was a postoperative nurse on a hospital ship.
vice about what I should do, because she was a nurse of This all is a world away from my old life in Hollywood, but I
30 years. She said, “I’ve always thought you would make wouldn’t trade anything for my time at sea with my fellow
an excellent nurse, but I never wanted to push it. I figured Navy nurses and corpsmen and helping those in need.
I would let you find your path on your own.”
That was all the encouragement I needed. Once ac-
cepted into a nursing program, I contacted the local Navy
recruiter. After a rigorous application process, I was ac-
cepted into a program to become a Nurse Corps Officer,
and on graduation, I was commissioned as an ensign in
the United States Navy.
Nearly 3 years later, I have found military nursing to be a
phenomenal experience. I have the opportunity to provide
nursing care to active duty and retired service members
and their families. Additionally, it is my responsibility to
train our hospital corpsmen who regularly care for our
forward deployed sailors and marines. These young men
and women carry a heavy responsibility to provide first
responder care to our warfighters. As a Navy nurse, I Lt. Joseph Biddix, USN
have a direct role in mentoring them. There is no greater U.S. Navy Medical Center, Camp Lejeune, NC
reward than training newly enlisted corpsmen and seeing
Note: The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the
Department of the Navy, the Department of Defense, or the United States government.
Reference: Courtesy Lt. Joseph Biddix.
Nursing in Schools bridge health care and education, provide care coordi-
School nursing is an interesting, specialized practice of nation, advocate for quality student-centered care, and
professional nursing. In 2017 the National Association of collaborate to design systems that allow individuals and
School Nurses (NASN) defined school nursing as “a spe- communities to develop their full potential” (NASN,
cialized practice of nursing [that] protects and promotes 2017). To that end, school nurses facilitate positive stu-
student health, facilitates optimal development, and dent responses to normal development; promote health
advances academic success. School nurses, grounded in and safety, including a healthy environment; intervene
ethical and evidence-based practice, are the leaders who with actual and potential health problems; provide case
management services; and actively collaborate with oth- and students about treatment and prevention of trans-
ers to build student and family capacity for adaptation, mission. For children with special needs, school nurses
self-management, self-advocacy, and learning. must work closely with families, teachers, and the stu-
School nurses are in short supply. Very few states dents’ primary providers to care for these children while
achieve the federally recommended ratio of 1:750 (a at school—and these needs can be significant. Manage-
recommended minimum number of 1 school nurse for ment of the health of children with diabetes and serious
every 750 students). In 2016 only 8 states had set a nurse- allergies is important in the daily life of school nurses.
to-student ratio; however, these ratios were not neces- School nurses work closely with teachers to incorpo-
sarily consistent with the guidelines set by the Centers rate health concepts into the curriculum. They endorse
for Disease Control and Prevention (CDC) and NASN. the teaching of basic health practices, such as hand-
For instance, Pennsylvania’s ratio was set at 1 nurse washing and caring for teeth. School nurses encourage
per 1500 students, twice the prescribed ratio (Camera, the inclusion of age-appropriate nutritional information
2016). This poses a serious problem for children with in school curricula and work with children to make
disabilities, for those with chronic illnesses in need of healthful food choices in the cafeteria and when choos-
occasional management at school, and for children who ing snacks. They conduct vision and hearing screenings
become ill or are injured at school. With higher than and make referrals to physicians or other health care
recommended ratios of students per RN, children may providers when routine screenings identify problems
lack the substantial health benefits of having a school outside the nurses’ scopes of practice.
nurse available to them during the school day. School nurses must be prepared to handle both rou-
School nursing has the potential to be a significant tine illnesses of children and adolescents and emergencies.
source of communities’ health care. In medically under- One of their major concerns is safety. Accidents are the
served areas and with the number of uninsured fami- leading cause of death in children of all ages, yet some acci-
lies increasing, the role of school nurse is sometimes dents are preventable. Prevention includes both protection
expanded to include members of the student’s imme- from obvious hazards and education of teachers, parents,
diate family. This requires many more school nurses— and students about how to avoid accidents. School nurses
requiring willingness of state and local school boards work with teachers, school bus drivers, cafeteria workers,
to hire them. Without adequate qualified staffing, the and other school employees to provide the safest possible
nation’s children cannot receive the full benefits of environment. When accidents occur, first aid for minor
school nurse programs. injuries and emergency care for more severe ones are
Most school systems require nurses to have a min- additional skills school nurses use (Fig. 1.4). Detection of
imum of a bachelor’s degree in nursing, whereas some evidence of child neglect and abuse is a sensitive but essen-
school districts have higher educational requirements. tial aspect of school nursing. School violence or bullying
Prior experience working with children is also usually can also result in injury, absenteeism, and anxiety. In the
required. School health has become a specialty in its wake of school violence involving guns and the possibil-
own right, and in states where school health is a priority of experiencing a natural disaster, the NASN has made
ity, graduate programs in school health nursing have disaster preparedness a priority.
been established. The National Board for Certification The mission of NASN is “advancing school nurse
of School Nurses (NBCSN) is the official certifying body practice to keep students healthy, safe, and ready to
for school nurses. learn” (www.nasn.org). This underscores their commit-
School nurses need a working knowledge of human ment to both the health and education of schoolchildren
growth and development to detect developmental prob- across the United States. The NASN 2013–2014 annual
lems early and refer children to appropriate therapists. report noted that sensitivity to the cultural needs of stu-
Counseling skills are important because many children dents is important in assisting with a child’s health and
turn to the school nurse as a counselor. School nurses to that end created a section on their website focusing
keep records of children’s required immunizations and on cultural competence. An important recent initiative
are responsible for ensuring that immunizations are cur- by the NASN has been to address the epidemic of child-
rent. When an outbreak of a childhood communicable hood obesity, creating a CE program for school nurses
illness occurs, school nurses educate parents, teachers, to provide them with resources and skills to address the
In the past decade, schools of nursing and other

nursing organizations have increased attention to this
important realm of care. According to the American
Nurses Association (ANA) document Hospice and Pal-
liative Care Nursing: Scope and Standards of Practice,
“Hospice and palliative care nursing reflects a holis-
tic philosophy of care implemented across the lifespan
and across diverse health settings. The goal of hospice
and palliative nursing is to promote and improve the
patient’s quality of life through the relief of suffering
along the course of the illness, through the death of the
patient, and into the bereavement period of the family”
(ANA, 2007, p. 1). Three major concepts are founda-
tional to end-of-life care (ANA, 2007):
1. Persons are living until the moment of death.
2. Coordinated care should be offered by a variety of
professionals, with attention to the physical, psycho-
logical, social, and spiritual needs of patients and
their families.
3. Care should be sensitive to patient and family diver-
sity (or cultural beliefs).
Fig. 1.4 School nurses manage a variety of students’ health In 1986 the Hospice and Palliative Nurses Association
problems, from playground injuries to chronic illnesses such (HPNA) was established, and it is now the largest and
as asthma and diabetes. (Photo used with permission from oldest professional nursing organization dedicated to the
iStockphoto.) practice of hospice and palliative care. HPNA has a jour-
nal, JHPN—Journal of Hospice and Palliative Nursing, a
problems and challenges of overweight and obese chil- peer-reviewed publication that promotes excellence
dren (NASN Annual Report, 2014). in end-of-life care, which is published six times each
year and can be followed on Twitter at @JHPN_online.
Nursing in Palliative Care and End-of-Life Settings HPNA’s website is https://advancingexpertcare.org/
Hospice and palliative care nursing is a nursing spe- and can be followed on Twitter at @HPNAinfo. In addi-
cialty dedicated to improving the quality of life of patients tion to HPNA, two other organizations are central to
who are seriously or terminally ill and their families. The supporting this domain of nursing: the Hospice and Pal-
World Health Organization (WHO) defines palliative liative Nurses Foundation (HPNF) and the Hospice and
care as “an approach that improves the quality of life of Palliative Credentialing Center (HPCC). In 2014 these
patients and their families facing the problem associated three organizations adopted shared mission and vision
with life-threatening illness, through the prevention and statements, in addition to pillars of excellence held in
relief of suffering by means of early identification and common. The shared mission is “advancing expert care
impeccable assessment and treatment of pain and other in serious illness” and the shared vision is “transform-
problems, physical, psychosocial and spiritual” (WHO, ing the care and culture of serious illness.” The pillars
2018). Hospice care is “the model for quality, compas- on which these organizations base their work are edu-
sionate care for people facing a life-limiting illness or cation, competence, advocacy, leadership, and research
injury” and involves an interdisciplinary approach to (HPNA, 2015).
symptom management, including pain management Because nursing curricula traditionally have not
and emotional and spiritual support shaped to the included extensive content to prepare nurses to deal effec-
specific needs of the patient and family as the patient tively with dying patients and their families, the AACN
approaches the end of his or her life (National Hospice developed CARES: Competencies and Recommendations
and Palliative Care Organization, 2018). for Educating Undergraduate Nursing Students Preparing
Nurses to Care for the Seriously Ill and Their Families. glucose, oxygen levels) (healthit.gov, 2017). The use
This document provides palliative care competencies for of telehealth devices expands access to health care for
the undergraduate nursing student and may be viewed underserved populations and individuals in both urban
online at http://www.aacnnursing.org/Portals/42/EL- and rural areas. Telehealth can also reduce the sense of
NEC/PDF/New-Palliative-Care-Competencies.pdf. professional isolation experienced by those who work
In 2000 End-of-Life Nursing Education Consortium in such areas and may assist in attracting and retaining
(ELNEC) was funded by the Robert Wood Johnson health care professionals in remote areas.
Foundation, and it has since received additional fund- Technologies available for telehealth nurses include
ing by a variety of organizations. The foundation for the remote access to laboratory reports and digitalized imag-
ELNEC project reflects the core areas identified by the ing; counseling patients on medications, diet, activity, or
AACN in the CARES document. As of 2015, more than other therapy on mobile phones or by voice-over-Inter-
19,500 nurses and other providers had received ELNEC net (VOI) protocol services (e.g., Skype; FaceTime); or
education in “train the trainer” symposia. These new participating in interactive video sessions, such as an
ELNEC trainers then returned to their communities interdisciplinary team consultation about a complex
and institutions and have educated more than 600,000 patient issue. Although the fundamentals of basic nurs-
other nurses and providers in end-of-life care. Currently ing practice do not change because of the nurse’s use of
there are seven available curricula: core, pediatric palli- telehealth technologies, their use may require adapta-
ative care, critical care, geriatric, advance practice regis- tion or modification of usual procedures. In addition,
tered nurse, international, and veterans (AACN, 2018). telehealth nurses must develop competence in the use of
To expand the reach of CARES and ELNEC, AACN each new type of telehealth technology, which changes
launched six interactive online modules for under- rapidly.
graduate nursing students. The online ELNEC mod- Numerous legal and regulatory issues surround
ules had more than 200 schools and more than 7000 nursing care delivered through telehealth technolo-
users enrolled in its first year. For more information see gies; for instance, care of patients across state lines may
http://elnec.academy.reliaslearning.com. require licensing in the state not only where the nurse is
Hospice and palliative care nurses work in a variety employed but also where the patients reside. The Rob-
of settings, including inpatient palliative/hospice units, ert J. Waters Center for Telehealth and e-Health Law
free-standing residential hospices, community-based or (www.ctel.org) (2018) is a clearinghouse organization
home hospice programs, ambulatory palliative care pro- for information about legal and regulatory issues related
grams, teams of consultants in palliative care, and SNFs. to telehealth, including nurse licensure, credentialing,
Both generalists and APNs work in palliative care. Medicare and Medicaid reimbursement, and other issues
related to the provision of health care from a distance.
Information Technologies in Nursing: Telehealth You can learn more about telehealth, an area of growing
and Informatics interest in nursing and other health professions, as well
Telehealth is the delivery of health care services and as some controversy, from the Association of Telehealth
related health care activities through telecommunica- Service Providers (www.atsp.org), from the American
tion technologies. Telehealth nursing (also known as Telemedicine Association (www.americantelemed.org),
telenursing or nursing telepractice) is not a separate nurs- and from the American Academy of Ambulatory Care
ing specialty, because few nurses use telehealth systems Nursing (www.aaacn.org).
exclusively in their practices. Rather, it is most often Nursing informatics (NI) is a rapidly evolving spe-
found as a part of other nursing roles. Current technol- cialty area defined by the Nursing Informatics Nursing
ogy includes bedside computers, interactive audio and Group as “the science and practice [integrating] nurs-
video links, teleconferencing, real-time (synchronous) ing, its information and knowledge, with management
transmission of patients’ diagnostic and clinical data, of information and communication technologies to
and more. The fastest growing applications of these tech- promote the health of people, families, and communi-
nologies are phone triage, remote monitoring, and home ties worldwide” (American Medical Informatics Asso-
care. Some aspects of patient health can be monitored ciation, 2015). Informatics nurses (also known as nurse
from a distance via remote patient monitoring (RPM) informaticians) were well positioned to assist in the
and include physiologic data (e.g., blood pressure, blood implementation of the 2009 American Recovery and
Reinvestment Act and the Health Information Tech- Thede (2012) published an interesting retrospective
nology Act. This legislation contained federal incentives on NI, describing the developments that she has seen
for the adoption of electronic health records (EHRs) in this field over the past 30 years, reporting that basic
with criteria known as meaningful use. To qualify for computer skills, informatics knowledge, and informa-
Centers for Medicare and Medicaid Services (CMS) tion literacy are three “threads” of importance to nurs-
incentive payments, health care organizations had to ing. She noted that one of the failures of “early dreamers”
select, implement, enhance, and/or measure the impact in informatics was not considering the cultural changes
of EHRs on patient care. Meaningful Use (MU) was a that would be required to move into a multidisciplinary
three-stage initiative implemented in 2011–2016. MU perspective regarding the use of information in health
focused on the use of technology to improve patient out- care settings, including “abandonment of the paper
comes through the engagement of patients and families, chart mentality.” With the incentives from CMS driving
improved care coordination, and increased privacy and the widespread adoption of EHR, nurse informaticians
security of patient information. MU is now included as will be instrumental in moving the development of these
part of the Medicare Access and Chip Reauthorization technologies into clinical usefulness with the goal of
Act, which focuses on merit-based incentives and the improving the population’s health.
use of EHR technology for multiple purposes, including
quality care (HealthIT.gov, 2017). Nursing in a Faith Community
Because they are nurses themselves, nurse informati- Interest in spirituality and its relation to wellness and
cians are best able to understand the needs of nurses who healing in recent years prompted the development of
use the systems and can customize or design them with the rapidly growing practice specialty of faith commu-
the needs, skills, and time constraints of those nurses nity nursing (FCN), previously known as parish nurs-
in mind. In contrast to computer science systems ana- ing. “FCN is a nursing practice specialty that focuses on
lysts, nurse informaticians must clearly understand the the intentional care of the spirit, promotion of an inte-
information they handle and how other nurses will use grative model of health, and prevention and minimiza-
it. According to the 2017 Healthcare Information and tion of illness within the context of a faith community”
Management Systems Society Nursing Informatics Work (ANA, 2017). FCN takes a holistic approach to healing
Survey, nurses in this field were overall satisfied with that involves partnerships among congregations, their
their work. Their two main job responsibilities included pastoral staffs, and health care providers. Since its devel-
systems implementation and utilization/optimization, opment in the Chicago area in the 1980s by a hospital
suggesting that their role is imperative in the effective use chaplain, Dr. Granger E. Westberg, FCN has spread rap-
of electronic medical and health records (EMR/EHR) idly and now includes more than 15,000 nurses in paid
(2018). and volunteer positions in a variety of religious faiths,
As health care organizations continue to adopt and cultures, and countries.
implement EHRs, nurse informaticians will be in increas- The FCN reclaims the historical custom of health
ing demand. and healing found in many faith traditions. The spiritual
At a minimum, nurses specializing in informatics dimension is central to FCN practice with a focus on
should have a BSN and additional knowledge and expe- the intentional care of the spirit while assisting individ-
rience in the field of informatics. An increasing number uals and faith-based communities to regain wholeness
of nurse informaticians have advanced degrees, includ- in body, mind, and spirit (Westberg Institute for Faith
ing doctorates. Certification as an informatics nurse Community Nursing, 2018). FCNs are instrumental in
is available through the ANCC. The American Med- connecting individuals disconnected from the health
ical Informatics Association (AMIA; www.amia.org) care system with preventative services and local health
and the Health Information and Management Systems care resources, can clarify provider orders, and iden-
Society (HIMSS; www.himss.org) sponsor the Alliance tify and recommend needed medical care (Schroepfer,
for Nursing Informatics (ANI), whose mission is to 2016). Research with small FCN projects and partner-
“advance nursing informatics practice, education, policy ships demonstrates the benefits of the combined health
and research through a unified voice of nursing infor- and spiritual ministry; however, follow-up research
matics organizations” (ANI, 2015). The ANI website is that can more broadly address the impact of the FCN is
www.allianceni.org. needed (Schroepfer, 2016).
Since 1997 the ANA (2017) has recognized FCM as a of nursing. Others have started nurse-based practices
specialty nursing practice within diverse faith communi- and carry their own caseloads of patients with physical
ties. The Health Ministries Association Inc. and the ANA or emotional needs. They are sometimes involved in
in their third edition of Faith Community Nursing: Scope presenting educational workshops and seminars. Some
and Standards of Practice collaboratively define six stan- nurses establish their own apparel businesses, manufac-
dards of practice for FCN and 11 standards of professional turing clothing for premature babies or for persons with
performance (ANA, 2017). Faith community nurses physical challenges. Others own and operate their own
serve as members of the pastoral team in a faith com- health equipment companies, health insurance agencies,
munity. The practice of FCN is governed by the nurse’s and home health agencies. Still others invent products
state nurse practice act, Nursing: Scopes and Standards of such as stethoscope covers that can be changed between
Practice (ANA, 2015a), Faith Community Nursing: Scope patients to prevent the spread of infection. Here are a few
and Standards (ANA, 2017), and the Code of Ethics for comments from one such entrepreneur, the chief exec-
Nurses with Interpretive Statements (ANA, 2015b). FCNs utive officer of a privately owned home health agency:
work as health educators and counselors, advocates for
I enjoy working for myself. I know that my success
health services, referral agents, and coordinators of vol-
or failure in my business is up to me. Having your
unteer health ministers. Faith community nurses often
own home health agency is a lot of work. You have
sponsor health screenings and facilitate support groups
to be very organized, manage other people effec-
while integrating the concepts of health and spirituality.
tively, and have excellent communication skills. You
Many FCNs work independently and benefit from net-
cannot be afraid to say no to the people. There is
working with other FCNs. Throughout the United States,
nothing better than the feeling I get when a fam-
many local and regional FCN organizations support FCN
ily calls to say our nurses have made a difference in
networking and collaboration, providing grant oppor-
their loved one’s life, but I also have to take the calls
tunities and even specialized training in the ministry
of complaint about my agency. Those are tough.
of FCN practice. Nurses interested in FCN may pursue
specialized training with a local or regional FCN orga- Increasingly, nurses are entering the business of
nization. According to the Westberg Institute for Faith health care, finding increasing opportunities to create
Community Nursing (2018), an FCN should (1) main- their own companies. One such company offers nursing
tain an active nursing license in the state of practice; (2) care for mothers, babies, and children. This company’s
have a baccalaureate degree in nursing with experience in emphasis is the care of women whose pregnancies may
community nursing; (3) have completed an educational be complicated by diabetes, hypertension, or multiple
course to prepare for FCN practice; (4) have specialized births. The RN who founded this company described
knowledge of the spiritual beliefs and practices of the the services offered by her company:
faith community; (5) reflect personal spiritual maturity in
his or her practice; and (6) be organized, flexible, a self- Our main specialty is managing high-risk pregnan-
starter, and an excellent communicator. cies and high-risk newborns. Home care for these
individuals is a boon not only to the patients them-
Nurses in Business: Entrepreneurs selves but also to hospitals, insurance companies, and
Some nurses are highly creative and are challenged by doctors. Now with shorter hospital stays, risks are
the risks of starting a new enterprise. Such nurses may minimized if skilled maternity nurses are on hand to
make good nurse entrepreneurs. provide patients with specialty care in their homes.
Similar to an entrepreneur in any field, a nurse As with almost any endeavor, disadvantages come
entrepreneur identifies a need and creates a service to with owning a business, such as the risk of losing your
meet the identified need. Nurse entrepreneurs enjoy the financial investment if the business is unsuccessful. Fluc-
autonomy derived from owning and operating their tuations in income are common, especially in the early
own health-related businesses. Groups of nurses, some months, and regular paychecks may be somewhat rare,
of whom are faculty members in schools of nursing, at least in the beginning. A certain amount of pressure
have opened nurse-managed centers to provide direct is created because of the total responsibility for meeting
care to clients. Nurse entrepreneurs are self-employed deadlines and paying bills, salaries, and taxes, but there
as consultants to hospitals, nursing homes, and schools is great opportunity as well.
In addition to financial incentives, there are also savvy have tremendous opportunities as entrepreneurs.
intangible rewards in entrepreneurship. For some peo- The website www.nursingentrepreneurs.com provides a
ple, the autonomy and freedom to control their own long list of categories of businesses operated by nurse
practice are more than enough to compensate for the entrepreneurs, the variety of which is extensive (e.g.,
increased pressure and initial uncertainty. movie set nurses, holistic life change strategists, med-
With rapid changes occurring daily in the health care ical bill auditing, nurse poet, nursing business startup
system, new and exciting possibilities abound. Alert coaching). In Professional Profile Box 1.2, you can read
nurses who possess creativity, initiative, and business a description of the career of Kay Wagoner, PhD, RN,
PROFESSIONAL PROFILE BOX 1.2 NURSE ENTREPRENEUR

It is my belief that everyone should go to nursing school, Thus for the next 20 years, I explored the discovery
because it prepares one for diverse professional opportu- and development of new treatments and medications
nities and life in general. My life has taken several tumbles by founding the science-based drug discovery company
and turns, careening forward, backward, up, and down. At Icagen, Inc., which was sold to Pfizer, Inc., in 2011. As
each point along the way, there were reasons to be forev- the CEO and president of Icagen, I used my nursing back-
er grateful to nursing. Nursing taught me to look in more ground to provide focus on truly unmet medical needs
detail at incongruences, to seek the essence of each di- such as new treatments for sickle cell disease, arrhyth-
lemma, while keeping a holistic perspective. I have been a mias, epilepsy, and pain. We sought to make data-driven
consistent collector of data, be it from direct patient experi- decisions by asking and answering the question, “What
ence, from educational endeavors, or from scientific exper- are the most efficacious and safe mechanisms to target
imentation. Although the data always molded my thinking, for new treatments to improve patient outcomes?”
final decisions were based on a desire to do something Today I am working with nurse educators and entre-
that made a difference in health and health care. preneurs and can be often heard asking, “How can we
I cherished my time in intensive care nursing, one of my innovate to make a difference?” Our great nursing profes-
first careers, because it was there that I began to appre- sion can lead us down many different career paths, some
ciate the need to better understand organ systems and clearly more direct than mine. Along the way we can let
cellular interactions to intervene with the critically ill on a nursing help drive evidence-based decision making to
moment-to-moment basis. My desire to learn more about make a positive difference in health and health care.
how one responds to a variety of health challenges and
life crises propelled me to advance my nursing education
at the master’s level.
With my newly minted master’s degree and a specialty
in cardiovascular nursing, I was challenged to teach under-
graduate nursing students that which I strove hardest to un-
derstand: how organ systems and the cells that comprised
them functioned and malfunctioned. While learning through
teaching, my nursing practice shifted to cardiovascular dis-
ease prevention and rehabilitation. I founded my first com-
pany, which provided a new treatment paradigm for individ-
uals attempting to stave off or repair from cardiovascular
disease. This combination of teaching and practice provided
great growth opportunities for me, including the confidence
to delve deeper into the science of health and disease.
I went back to the classroom and completed doctoral
and postdoctoral studies in physiology and pharmacolo-
gy. I gained a more complete understanding of how cells,
organ systems, and the human body works and fails. I
also came to realize that many of the available treatments
were too little too late and many of the available medica- Kay Wagoner, PhD, RN
tions woefully inadequate in terms of efficacy and safety. (Cardiovascular Nurse Specialist)
Reference: Courtesy Kay Wagoner.

whose career in nursing gave her expertise in cardiovas- and communities and is prepared to facilitate a culture
cular nursing; using her knowledge from nursing, she of safety for specific groups of patients with the goal of
founded her own drug development company. improving patient outcomes (Rankin, 2015).
The role of CNL was not without controversy and
NURSING OPPORTUNITIES REQUIRING objections from CNSs, who are APNs and who saw
the proposed role as duplicating and potentially disen-
ADVANCED DEGREES franchising CNSs. Currently, 117 schools affiliated with
Many RNs choose to pursue careers that require a mas- AACN offer CNL programs. More information can be
ter’s degree, doctoral degree, or specialized education in found on the AACN’s website: http://www.aacnnursing
a specific area. These roles include clinical nurse leaders, .org/CNL/About.
nurse managers, nurse executives in hospital settings,
nurse educators (whether in clinical or academic set- Advanced Practice Nursing
tings), nurse anesthetists, nurse-midwives, clinical nurse Advanced practice nursing is a general term applied to
specialists, and advanced practice nursing in a variety of an RN who has met advanced educational and clinical
settings. Some of these careers are described next. practice requirements beyond the 2 to 4 years of basic
nursing education required of all RNs. Advanced prac-
Nurse Educators tice nursing has grown since it evolved more than 40
In 2008, 98,268 RNs reported working in academic years ago. The 2017 workforce data reports that more
education programs (U.S. Department of Health and than 250,000 nurses are practicing in advanced prac-
Human Services, 2010). Since 2005, more than 5300 tice roles, and the projected demand for these roles will
nurse educators have achieved specialty certification as increase by over 30% in the next 10 years (Bureau of
certified nurse educators through the National League Labor Statistics, 2018; National Association of Clinical
of Nursing (Simmons, 2017). Nurse educators teach in Nurse Specialists, 2018). Increased demand for primary
licensed practical nurse/licensed vocational nurse pro- care coupled with increased specialization of physicians
grams, diploma programs, associate degree programs, and heightened demand for efficient and cost-effective
bachelor’s and higher degree programs, and programs treatment mean that advanced practice poses excellent
preparing nursing assistants. Nurse educators in accred- career opportunities for nurses. The implementation of
ited schools of nursing offering a bachelor’s or higher the Affordable Care Act stimulated even greater interest
degree must hold a minimum of a master’s degree in and growth in the numbers of APNs. Patient acceptance
nursing. The NLN (2015) in their 2014–2015 faculty of APNs is high, and the evidence consistently demon-
census survey identified 1072 full-time nursing faculty strates that APNs provide high-quality, cost-effective
vacancies, with approximately one-third of the vacancies care that can reduce the burden of the growing short-
at the baccalaureate level. The NLN (2015) found that age of primary care providers (Swan et al., 2015). There
a lack of qualified candidates and an inability to offer are four categories of APNs: nurse practitioner, clinical
competitive salaries as the main difficulties in recruiting nurse specialist, certified nurse-midwife, and certified
new nurse educators. Concerns about a critical shortage registered nurse anesthetist.
of nursing faculty in the future continue.
Nurse Practitioner
Clinical Nurse Leaders Opportunities for nurses in expanded roles in health
One of the newer credentials approved by the AACN care have created a demand in nurse practitioner (NP)
is the clinical nurse leader (CNL). This designation education. These programs grant master’s degrees or
was intended as a means of allowing master’s-prepared post-master’s certificates and prepare nurses to sit for
nurses to oversee and manage care at the point of care national certification examinations as NPs. The length of
in various settings. CNLs are not intended to be admin- the programs varies, depending on the student’s prior edu-
istrators or managers but are clinical experts who may, cation. Programs of study leading to the doctor of nursing
on occasion, actively provide direct patient care them- practice (DNP) degree have been implemented in schools
selves. The CNL is a generalist providing and managing of nursing across the country in response to the AACN
care at the point of care to patients, individuals, families, member institution’s endorsement of a clinical doctorate
for advanced practice. The DNP is consistent with other care, community health, or neonatal health, and they
health professions that offer practice doctorates, including perform health assessments, make diagnoses, deliver
medicine (MD), dentistry (DDS), pharmacy (PharmD), treatment, and develop quality control methods. In
physical therapy (DPT), and psychology (PsyD), among addition, CNSs work in consultation, research, educa-
others. There are currently 303 DNP programs actively tion, and administration. Direct reimbursement to some
enrolling students across all 50 states, and another 124 CNSs is possible through Medicare, Medicaid, and mili-
programs in the planning stages, which demonstrates the tary and private insurers.
rapid growth of this degree path (AACN, 2017).
States vary in the level of practice autonomy accorded Certified Nurse-Midwife
to NPs. NPs beginning practice in a new state should Certified nurse-midwives (CNMs) provide well-
check the status of the advanced practice laws in that woman care and attend or assist in childbirth in various
state before making firm commitments, because some settings, including hospitals, birthing centers, private
states still place limitations on NP independence. These practice, and home birthing services. By 2010 all CNM
barriers to practice include the variation of scope of training programs were required to award a master’s
practice across states (with implications for practice of science in nursing (MSN) degree. CNM programs
opportunities); lack of physician understanding of NP require an average of 1.5 years of specialized education
scope of practice (limits successful collaboration); and beyond basic nursing education and must be accredited
payer policies that are linked to state practice regula- by the Accreditation Commission for Midwifery Educa-
tions (Hain and Fleck, 2014). tion (ACME).
NPs work in clinics, nursing homes, their own offices, CNMs are licensed, independent health care provid-
or physicians’ offices. Others work for hospitals, health ers who can prescribe medications in all 50 states, the
maintenance organizations, or private industry. Most District of Columbia, and most U.S. territories. Fed-
NPs choose a specialty area such as adult–gerontology, eral law designates CNMs as primary care providers.
psychiatric–mental health, family, or pediatric care. They More than half of CNMs identify reproductive care as
are qualified to handle a wide range of health problems in their main responsibility rather than attending births.
primary or acute care settings. These nurses can perform According to the National Center for Health Statistics,
physical examinations, take medical histories, diagnose CNMs attended 332,107 births in 2014, representing
and treat common acute and chronic illnesses and inju- more than 8% of the total births in the United States
ries, order and interpret laboratory tests and x-ray films, in 2014 (American College of Nurse-Midwives, 2016).
and counsel and educate patients. Despite the restrictions Historically, births attended by CNMs have had half
on practice in some states, in other states, NPs are inde- the national average rates for cesarean sections and
pendent practitioners with full prescriptive authority and higher rates of successful vaginal births after a previous
can be directly reimbursed by Medicare, Medicaid, and cesarean, both considered measures of high-quality
military and private insurers for their work. obstetric care. Karen Sheffield, MSN, CNM, describes
In Professional Profile Box 1.3, Sebastian White, her work as a certified nurse-midwife in Professional
MSN, FNP, BC-ADM, RN, describes his work as an NP Profile Box 1.4.
providing diabetes care in partnership with a physician
in Bozeman, Montana. Certified Registered Nurse Anesthetist
In 2015 there were approximately 48,000 certified regis-
Clinical Nurse Specialist tered nurse anesthetists (CRNAs) and CRNA students
Clinical nurse specialists (CNSs) are APNs who work in the United States (American Association of Nurse
in a variety of settings, including hospitals, clinics, nurs- Anesthetists [AANA], 2015). Nurse anesthetists admin-
ing homes, their own offices, industry, home care, and ister approximately 43 million anesthetics each year and
health maintenance organizations. These nurses hold are the only anesthesia providers in nearly one-third of
master’s or doctoral degrees and are qualified to handle U.S. hospitals (AANA, 2016). Collaborating with phy-
a wide range of physical and mental health problems. sician anesthesiologists or working independently, they
They are experts in a particular field of clinical practice, are found in a variety of settings, including operating
such as mental health, gerontology, cardiac care, cancer suites; obstetric delivery rooms; the offices of dentists,
PROFESSIONAL PROFILE BOX 1.3 DIABETES NURSE PRACTITIONER

I am a nurse practitioner who specializes in the care of recruited back to Montana by a large multispecialty clin-
persons with diabetes. I am also a father, a husband, ic—the Billings Clinic—where I was welcomed into their
and an endurance athlete. My path to nursing start- department of endocrinology. I was integral in the es-
ed as a young boy being raised by my mother, Angela tablishment of a comprehensive inpatient diabetes man-
Willett-Calnan, RN, and later, my maternal grandparents. agement program. Soon I was recruited by the hospital
My mother’s mother is also a nurse, Mary Grace Willett, in Bozeman to start a diabetes center with an internist
RN. Several other family members are health care pro- who is now my partner in practice. Back to the moun-
fessionals. tains I love! I am now the only National Committee for
As an undergraduate student, I graduated with a bache- Quality Assurance diabetes nurse practitioner in the Pa-
lor of science degree in biology and a minor in psychology cific Northwest.
while leading my college’s soccer team as captain for 2 Nursing is the greatest gift we can offer patients. Our
years. After college I moved to Bozeman, Montana, fall- health care system in the United States is broken—costs
ing in love with the high peaks of the Rocky Mountains. spiraling and measures of health worsening every year.
My original intent was to spend a summer in Montana As a nurse, I am trained to focus on the missing element
and then attend physical therapy school. That summer in our health care system: the patient. I am trained to
ended much too quickly! After 2 years of trying my best treat my patients, not their disease; I am trained to listen
to be a ski bum, I realized that I didn’t have much bum to their concerns and focus my interventions on helping
in me, so I attended an emergency medical technician them improve their lives. I am a nurse.
training course and became a member of the Big Sky To my wife, my mother, my grandmother, my uncle,
Professional Ski Patrol. There I was back in my element: and the high mountains of Montana: All the credit belongs
helping people. to you. Thank you.
My search for the next step began. I volunteered at
our local community health center, asking many ques-
tions of the providers there. I knew I wanted a role in
primary care, so medical or nursing school would be my
next step. The final decision was inspired by my uncle,
Dr. Michael Willett, who said to me, “Sebastian, I have
worked with and trained many nurse practitioners and
physicians. You are meant to be a nurse.” At that point,
I really had no idea what he meant—I was just relieved
to have a plan.
Energized, I enrolled in a nursing school offering an
accelerated bachelor of science in nursing for students
who already had a college degree. In my first nursing
position, I became interested in diabetes. After com-
pleting my master of science in nursing degree, I was Sebastian White, MSN, FNP, BC-ADM, RN
Reference: Courtesy Sebastian White.
podiatrists, ophthalmologists, and plastic surgeons; there were 114 accredited nurse anesthesia programs
ambulatory surgical facilities; and military and govern- in the United States, ranging from 24 to 36 months in
mental health services (AANA, 2015). length. Nurse anesthetists must also meet national cer-
To become a CRNA, nurses must complete 2 to 3 tification and recertification requirements. The safety of
years of specialized education in a master’s program care delivered by CRNAs is well established. Anesthesia
beyond the required bachelor’s degree; 32 nurse anes- care today is safer than in the past, and numerous out-
thesia programs are approved to award doctoral degrees come studies have demonstrated that there is “no differ-
for entry into CRNA practice, which is likely to be the ence in the quality of care provided by CRNAs and their
requirement in the near future (AANA, 2015). In 2014 physician counterparts” (AANA, 2015).
PROFESSIONAL PROFILE BOX 1.4 CERTIFIED NURSE-MIDWIFE

Being a nurse-midwife is at the core of who I am, not as well as seeing patients in the office. Evidence-based
just what I do. I decided to become a nurse-midwife af- care in the office setting includes contraceptive manage-
ter working as a chemist for many years and recognizing ment, family planning, primary care, gynecologic care, and
that my true passion resided in all aspects of women’s sick visits, among others. In addition to gynecologic care,
health care. After the birth of two of my children, one by nurse-midwives provide obstetric care that is grounded in
a physician and one by a nurse-midwife, I realized that I our belief that childbirth is a normal, healthy human event.
was “called” to the profession of nurse-midwifery and However, we are educated in how and when to collab-
the philosophy of care that nurse-midwives provide. De- orate with physician colleagues for emergent care that
livering comprehensive, holistic wellness care to women necessitates a physician’s specific expertise.
throughout their life span is one of the most rewarding I strongly believe that my role as a nurse-midwife is to be
and inspirational aspects of my profession. I feel privi- “with a woman” and to honor her journey toward health
leged and honored to share in the important and often and wellness, as well as respecting her wishes for her birth
life-changing decisions that women make during the within the limits of safety. When I reflect on my journey
many transitions that occur during the years between pu- as a nurse-midwife for the past decade, I know that I am
berty and menopause and beyond. truly carrying out my purpose in providing holistic women’s
I have a bachelor of arts in physics and received a mas- health care to the highest standard of excellence.
ter’s degree in nursing from Yale University in 2005 with a
specialty in nurse-midwifery. Additionally, I am certified in
nurse-midwifery by the American Midwifery Certification
Board (AMCB). Certification by the AMCB is considered
the gold standard in midwifery and is recognized in all
50 states. As a nurse-midwife, I must also complete the
requirements of the Certification Maintenance Program
through AMCB by completing continuing education units
every 5-year certification cycle. Maintaining competence
in evidence-based, up-to-date management and treatment
for women’s health is critical to being an effective clinician.
Although the professional work environment for
nurse-midwives varies, a typical day as a nurse-midwife
with a full scope of practice involves providing gynecolog-
ic, antepartum, intrapartum, and postpartum care, which Karen Sheffield, MSN, CNM
includes hospital rounds on patients who have given birth, Yale University, 2005
Reference: Courtesy Karen Sheffield, MSN, CNM.
Issues in Advanced Practice Nursing arena, with organized medicine positioned firmly
Each year in January, The Nurse Practitioner: The Amer- against all efforts of nurses to be recognized as indepen-
ican Journal of Primary Health Care publishes an update dent health care providers receiving direct reimburse-
on legislation affecting advanced practice nursing. Over ment for their services. Organized nursing, however,
the years, advances have been made toward removing persevered. Nurses, through their professional associa-
the barriers to autonomous practice for APNs in many, tions, continued their efforts to change laws that limit
but not all, states. the scope of nursing practice. Their efforts were aided
In the past, substantial barriers to APN autonomy by the fact that numerous published studies validated
existed because of the overlap between traditional medi- the safety, cost efficiency, and high patient acceptance of
cal and nursing functions. A decade ago, the picture was advanced practice nursing care.
considerably less optimistic than it is now. The issue of Both the public and legislators at state and national
APNs practicing autonomously was a politically charged levels have begun to appreciate the role that APNs have
played in increasing the efficiency and availability of patient length of stay, nursing home admissions will
primary health care delivery while reducing costs; how- increase, as will growth in long-term rehabilitation
ever, opposition to APN autonomy persists. Roadblocks units (U.S. Department of Labor, 2016).
to full practice autonomy continue, primarily because of An additional factor influencing employment pat-
the resistance of organized physician groups despite data terns for RNs is the tendency for sophisticated med-
indicating positive patient outcomes. Although progress ical procedures to be performed in physicians’ offices,
has been made, there remains the need for APNs to con- clinics, ambulatory surgical centers, and other outpa-
tinue to work with their professional organizations to tient settings. RNs’ expertise will be needed to care for
promote legislation mandating full autonomy. patients undergoing procedures formerly performed
only in hospital settings. APNs can also expect to be in
higher demand for the foreseeable future. The evolution
EMPLOYMENT OUTLOOK IN NURSING of integrated health care networks focusing on primary
The Bureau of Labor Statistics, a division of the U.S. care and health maintenance and pressure for cost-
Department of Labor, is confident about nursing’s over- effective care are ideal conditions for advanced practice
all employment prospects in the near and distant future. nursing.
According to the bureau (U.S. Department of Labor, Salaries in the nursing profession vary widely accord-
2016), nurses can expect their employment opportuni- ing to practice setting, level of preparation, credentials,
ties to grow “15% from 2016 to 2026, much faster than experience, and region of the country. According to the
average for all occupations.” The bureau estimates that, U.S. Board of Labor Statistics, in 2016, median annual
during this time, 438,100 new RN jobs will be created salary for nurses was $68,450 (as a comparison, the
to meet growing patient needs and to replace retiring median salary for all workers was $37,040). The lowest
nurses (U.S. Department of Labor, 2016). Several fac- paid 10% earned less than $47,120, and the highest paid
tors are fueling this growth, including technological 10% earned more than $102,990. Salaries were the high-
advances and the increasing emphasis on primary care. est with government and hospital employers and lowest
The aging of the nation’s population also has a signif- in educational services. About 21% of RNs are members
icant impact, because older people are more likely to of unions or are covered by union contracts. Interest-
require medical care. As aging nurses retire, many addi- ingly, California has the highest nursing salaries in the
tional job openings will result. United States and has a vigorous union in the California
Opportunities in hospitals, traditionally the largest Nurses Association/National Nurses United. Salaries in
employers of nurses, will grow more slowly than those nursing vary by region, as do salaries in other profes-
in community-based sectors. The most rapid hospital- sions and occupations.
based growth is projected to occur in outpatient facil- APNs have higher salaries than do staff nurses;
ities, such as same-day surgery centers, rehabilitation CRNAs average the highest salary of any advanced prac-
programs, and outpatient cancer centers. Home health tice specialty group. Clearly, in nursing as in most other
positions are expected to increase the fastest of all. This professions, additional preparation and responsibility
is in response to the expanding elderly population’s increase earning potential.
needs and the preference for and cost effectiveness of Most of the wage growth for nurses occurs early in
home care. Furthermore, technological advances are their careers and tapers off as nurses near the top of the
making it possible to bring increasingly complex treat- salary scale. This leads to a flattening of salaries for more
ments into the home. experienced nurses in a phenomenon known as wage
Another expected area of high growth is in assisted compression. Wage compression may account for nurses
living and nursing home care; this is primarily in leaving patient care for additional education or other
response to the larger number of frail elderly in their careers in nursing or outside the profession, an issue
80s and 90s requiring long-term care. As hospitals that must be addressed to improve retention of the most
come under greater pressure to decrease the average experienced nurses in the profession.
C O N C E P T S A N D C H A L L E N G E S
Concept: Nursing is the largest workforce in health
• for nurses. Increased use of APNs as providers of pri-
care in the United States. mary care may be part of the solution to the Ameri-
Challenge: The influence of nursing is not as pow- can health care crisis as the “baby boom” generation
erful as it could be because the large majority of ages, the numbers of elderly increase, and the need for
nurses do not belong to professional organizations health care cost containment becomes critical.
such as the ANA, a federation of state nurses asso- Challenge: APNs are capable of delivering high-quality
ciations that is the voice of nursing. care to many segments of the population who do not
Concept: More than half of working nurses are
• have adequate care; however, educating adequate
employed in hospitals, a traditional setting for nurs- numbers of advanced practice nurses is essential to
ing practice. meet the demands on the health care system.
Challenge: As health care becomes increasingly based in Concept: Nursing will continue to be a profession in
•
the community, more nurses will be working outside high demand in the foreseeable future.
of the hospital. Nursing must consider the impact of Challenge: Nursing faculty shortages at all levels of
this migration from hospital to community. nursing education pose an ongoing challenge to
Concept: The Affordable Care Act and other changes in
• educate enough professional nurses to meet the
health care will create more opportunities for practice health needs of the population.
I D E A S F O R F U R T H E R E X P L O R A T I O N
1. Th
ink of the areas of nursing that interest you most. and salaries and other benefits for entry-level and
How do your personal interests and nursing educa- advanced practice nursing. Is there a clinical ladder
tion compare with the characteristics needed in the program? How does it work?
roles presented in this chapter? 4. Ask an advanced practice RN in your community
2. As you continue your nursing education, ask ques- about his or her practice. What are the advantages
tions of nurses in various practice settings to learn and major barriers to practice that this advanced
how they prepared for their positions, what their practice RN encounters?
work life is like, and what they find most challenging 5. Contact your state nurses association to find out
and rewarding about their work. what legislative initiatives are being undertaken to
3. Call the nurse recruiter or personnel office of a nearby remove barriers to full advanced practice nursing in
hospital to inquire about education, experience, your state.

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Another random document with
no related content on Scribd:
The Project Gutenberg eBook of The nature of
the physical world
This ebook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
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included with this ebook or online at www.gutenberg.org. If you
are not located in the United States, you will have to check the
laws of the country where you are located before using this
eBook.
Title: The nature of the physical world
Author: Sir Arthur Stanley Eddington
Release date: February 15, 2024 [eBook #72963]
Language: English
Original publication: New York: The Macmillan Company, 1928
Credits: Laura Natal Rodrigues (Images generously made

available by The Internet Archive.)
*** START OF THE PROJECT GUTENBERG EBOOK THE

NATURE OF THE PHYSICAL WORLD ***
THE NATURE OF THE
PHYSICAL WORLD
by
A. S. EDDINGTON
M.A., LL.D., D.SC., F.R.S.
Plumian Professor of Astronomy

in the
University of Cambridge
THE
GIFFORD LECTURES
1927
NEW YORK:
THE MACMILLAN COMPANY
CAMBRIDGE, ENGLAND:
AT THE UNIVERSITY PRESS
1929
All rights reserved

copyright, 1928,
By THE MACMILLAN COMPANY.
Set up and electrotyped.
Published November, 1928.
Reprinted February, 1929.
Twice. March, 1929.
Reprinted April, 1929.
set up by brown brothers linotypers

printed in the united states of america
by the ferris printing company
PREFACE
This book is substantially the course of Gifford Lectures which I
delivered in the University of Edinburgh in January to March 1927. It
treats of the philosophical outcome of the great changes of scientific
thought which have recently come about. The theory of relativity and
the quantum theory have led to strange new conceptions of the
physical world; the progress of the principles of thermodynamics has
wrought more gradual but no less profound change. The first eleven
chapters are for the most part occupied with the new physical
theories, with the reasons which have led to their adoption, and
especially with the conceptions which seem to underlie them. The
aim is to make clear the scientific view of the world as it stands at the
present day, and, where it is incomplete, to judge the direction in
which modern ideas appear to be tending. In the last four chapters I
consider the position which this scientific view should occupy in
relation to the wider aspects of human experience, including religion.
The general spirit of the inquiry followed in the lectures is stated in
the concluding paragraph of the Introduction (p. xvii).
I hope that the scientific chapters may be read with interest apart
from the later applications in the book; but they are not written quite
on the lines that would have been adopted had they been wholly
independent. It would not serve my purpose to give an easy
introduction to the rudiments of the relativity and quantum theories; it
was essential to reach the later and more recondite developments in
which the conceptions of greatest philosophical significance are to
be found. Whilst much of the book should prove fairly easy reading,
arguments of considerable difficulty have to be taken in their turn.
My principal aim has been to show that these scientific
developments provide new material for the philosopher. I have,
however, gone beyond this and indicated how I myself think the
material might be used. I realise that the philosophical views here
put forward can only claim attention in so far as they are the direct
outcome of a study and apprehension of modern scientific work.
General ideas of the nature of things which I may have formed apart
from this particular stimulus from science are of little moment to
anyone but myself. But although the two sources of ideas were fairly
distinct in my mind when I began to prepare these lectures they have
become inextricably combined in the effort to reach a coherent
outlook and to defend it from probable criticism. For that reason I
would like to recall that the idealistic tinge in my conception of the
physical world arose out of mathematical researches on the relativity
theory. In so far as I had any earlier philosophical views, they were of
an entirely different complexion.
From the beginning I have been doubtful whether it was desirable
for a scientist to venture so far into extra-scientific territory. The
primary justification for such an expedition is that it may afford a
better view of his own scientific domain. In the oral lectures it did not
seem a grave indiscretion to speak freely of the various suggestions
I had to offer. But whether they should be recorded permanently and
given a more finished appearance has been difficult to decide. I have
much to fear from the expert philosophical critic, but I am filled with
even more apprehension at the thought of readers who may look to
see whether the book is “on the side of the angels” and judge its
trustworthiness accordingly. During the year which has elapsed since
the delivery of the lectures I have made many efforts to shape this
and other parts of the book into something with which I might feel
better content. I release it now with more diffidence than I have felt
with regard to former books.
The conversational style of the lecture-room is generally
considered rather unsuitable for a long book, but I decided not to
modify it. A scientific writer, in forgoing the mathematical formulae
which are his natural and clearest medium of expression, may
perhaps claim some concession from the reader in return. Many
parts of the subject are intrinsically so difficult that my only hope of
being understood is to explain the points as I would were I face to
face with an inquirer.
It may be necessary to remind the American reader that our
nomenclature for large numbers differs from his, so that a billion here
means a million million.
A. S. E.
August 1928
INTRODUCTION
I have settled down to the task of writing these lectures and have
drawn up my chairs to my two tables. Two tables! Yes; there are
duplicates of every object about me—two tables, two chairs, two
pens.
This is not a very profound beginning to a course which ought to
reach transcendent levels of scientific philosophy. But we cannot
touch bedrock immediately; we must scratch a bit at the surface of
things first. And whenever I begin to scratch the first thing I strike is
—my two tables.
One of them has been familiar to me from earliest years. It is a
commonplace object of that environment which I call the world. How
shall I describe it? It has extension; it is comparatively permanent; it
is coloured; above all it is substantial. By substantial I do not merely
mean that it does not collapse when I lean upon it; I mean that it is
constituted of “substance” and by that word I am trying to convey to
you some conception of its intrinsic nature. It is a thing; not like
space, which is a mere negation; nor like time, which is—Heaven
knows what! But that will not help you to my meaning because it is
the distinctive characteristic of a “thing” to have this substantiality,
and I do not think substantiality can be described better than by
saying that it is the kind of nature exemplified by an ordinary table.
And so we go round in circles. After all if you are a plain
commonsense man, not too much worried with scientific scruples,
you will be confident that you understand the nature of an ordinary
table. I have even heard of plain men who had the idea that they
could better understand the mystery of their own nature if scientists
would discover a way of explaining it in terms of the easily
comprehensible nature of a table.
Table No. 2 is my scientific table. It is a more recent acquaintance
and I do not feel so familiar with it. It does not belong to the world
previously mentioned—that world which spontaneously appears
around me when I open my eyes, though how much of it is objective
and how much subjective I do not here consider. It is part of a world
which in more devious ways has forced itself on my attention. My
scientific table is mostly emptiness. Sparsely scattered in that
emptiness are numerous electric charges rushing about with great
speed; but their combined bulk amounts to less than a billionth of the
bulk of the table itself. Notwithstanding its strange construction it
turns out to be an entirely efficient table. It supports my writing paper
as satisfactorily as table No. 1; for when I lay the paper on it the little
electric particles with their headlong speed keep on hitting the
underside, so that the paper is maintained in shuttlecock fashion at a
nearly steady level. If I lean upon this table I shall not go through; or,
to be strictly accurate, the chance of my scientific elbow going
through my scientific table is so excessively small that it can be
neglected in practical life. Reviewing their properties one by one,
there seems to be nothing to choose between the two tables for
ordinary purposes; but when abnormal circumstances befall, then my
scientific table shows to advantage. If the house catches fire my
scientific table will dissolve quite naturally into scientific smoke,
whereas my familiar table undergoes a metamorphosis of its
substantial nature which I can only regard as miraculous.
There is nothing substantial about my second table. It is nearly all
empty space—space pervaded, it is true, by fields of force, but these
are assigned to the category of “influences”, not of “things”. Even in
the minute part which is not empty we must not transfer the old
notion of substance. In dissecting matter into electric charges we
have travelled far from that picture of it which first gave rise to the
conception of substance, and the meaning of that conception—if it
ever had any—has been lost by the way. The whole trend of modern
scientific views is to break down the separate categories of “things”,
“influences”, “forms”, etc., and to substitute a common background of
all experience. Whether we are studying a material object, a
magnetic field, a geometrical figure, or a duration of time, our
scientific information is summed up in measures; neither the
apparatus of measurement nor the mode of using it suggests that
there is anything essentially different in these problems. The
measures themselves afford no ground for a classification by
categories. We feel it necessary to concede some background to the
measures—an external world; but the attributes of this world, except
in so far as they are reflected in the measures, are outside scientific
scrutiny. Science has at last revolted against attaching the exact
knowledge contained in these measurements to a traditional picture-
gallery of conceptions which convey no authentic information of the
background and obtrude irrelevancies into the scheme of knowledge.
I will not here stress further the non-substantiality of electrons,
since it is scarcely necessary to the present line of thought.
Conceive them as substantially as you will, there is a vast difference
between my scientific table with its substance (if any) thinly scattered
in specks in a region mostly empty and the table of everyday
conception which we regard as the type of solid reality—an incarnate
protest against Berkleian subjectivism. It makes all the difference in
the world whether the paper before me is poised as it were on a
swarm of flies and sustained in shuttlecock fashion by a series of tiny
blows from the swarm underneath, or whether it is supported
because there is substance below it, it being the intrinsic nature of
substance to occupy space to the exclusion of other substance; all
the difference in conception at least, but no difference to my practical
task of writing on the paper.
I need not tell you that modern physics has by delicate test and
remorseless logic assured me that my second scientific table is the
only one which is really there—wherever “there” may be. On the
other hand I need not tell you that modern physics will never
succeed in exorcising that first table—strange compound of external
nature, mental imagery and inherited prejudice—which lies visible to
my eyes and tangible to my grasp. We must bid good-bye to it for the
present for we are about to turn from the familiar world to the
scientific world revealed by physics. This is, or is intended to be, a
wholly external world.
“You speak paradoxically of two worlds. Are they not really two
aspects or two interpretations of one and the same world?”
Yes, no doubt they are ultimately to be identified after some
fashion. But the process by which the external world of physics is
transformed into a world of familiar acquaintance in human
consciousness is outside the scope of physics. And so the world
studied according to the methods of physics remains detached from
the world familiar to consciousness, until after the physicist has
finished his labours upon it. Provisionally, therefore, we regard the
table which is the subject of physical research as altogether separate
from the familiar table, without prejudging the question of their
ultimate identification. It is true that the whole scientific inquiry starts
from the familiar world and in the end it must return to the familiar
world; but the part of the journey over which the physicist has charge
is in foreign territory.
Until recently there was a much closer linkage; the physicist used
to borrow the raw material of his world from the familiar world, but he
does so no longer. His raw materials are aether, electrons, quanta,
potentials, Hamiltonian functions, etc., and he is nowadays
scrupulously careful to guard these from contamination by
conceptions borrowed from the other world. There is a familiar table
parallel to the scientific table, but there is no familiar electron,
quantum or potential parallel to the scientific electron, quantum or
potential. We do not even desire to manufacture a familiar
counterpart to these things or, as we should commonly say, to
“explain” the electron. After the physicist has quite finished his world-
building a linkage or identification is allowed; but premature attempts
at linkage have been found to be entirely mischievous.
Science aims at constructing a world which shall be symbolic of
the world of commonplace experience. It is not at all necessary that
every individual symbol that is used should represent something in
common experience or even something explicable in terms of
common experience. The man in the street is always making this
demand for concrete explanation of the things referred to in science;
but of necessity he must be disappointed. It is like our experience in
learning to read. That which is written in a book is symbolic of a story
in real life. The whole intention of the book is that ultimately a reader
will identify some symbol, say bread, with one of the conceptions of
familiar life. But it is mischievous to attempt such identifications
prematurely, before the letters are strung into words and the words
into sentences. The symbol is not the counterpart of anything in
familiar life. To the child the letter would seem horribly abstract; so
we give him a familiar conception along with it. “ was an Archer
who shot at a frog.” This tides over his immediate difficulty; but he
cannot make serious progress with word-building so long as Archers,
Butchers, Captains, dance round the letters. The letters are abstract,
and sooner or later he has to realise it. In physics we have outgrown
archer and apple-pie definitions of the fundamental symbols. To a
request to explain what an electron really is supposed to be we can
only answer, “It is part of the A B C of physics”.
The external world of physics has thus become a world of
shadows. In removing our illusions we have removed the substance,
for indeed we have seen that substance is one of the greatest of our
illusions. Later perhaps we may inquire whether in our zeal to cut out
all that is unreal we may not have used the knife too ruthlessly.
Perhaps, indeed, reality is a child which cannot survive without its
nurse illusion. But if so, that is of little concern to the scientist, who
has good and sufficient reasons for pursuing his investigations in the
world of shadows and is content to leave to the philosopher the
determination of its exact status in regard to reality. In the world of
physics we watch a shadowgraph performance of the drama of
familiar life. The shadow of my elbow rests on the shadow table as
the shadow ink flows over the shadow paper. It is all symbolic, and
as a symbol the physicist leaves it. Then comes the alchemist Mind
who transmutes the symbols. The sparsely spread nuclei of electric
force become a tangible solid; their restless agitation becomes the
warmth of summer; the octave of aethereal vibrations becomes a
gorgeous rainbow. Nor does the alchemy stop here. In the
transmuted world new significances arise which are scarcely to be
traced in the world of symbols; so that it becomes a world of beauty
and purpose—and, alas, suffering and evil.
The frank realisation that physical science is concerned with a
world of shadows is one of the most significant of recent advances. I
do not mean that physicists are to any extent preoccupied with the
philosophical implications of this. From their point of view it is not so
much a withdrawal of untenable claims as an assertion of freedom
for autonomous development. At the moment I am not insisting on
the shadowy and symbolic character of the world of physics because
of its bearing on philosophy, but because the aloofness from familiar
conceptions will be apparent in the scientific theories I have to
describe. If you are not prepared for this aloofness you are likely to
be out of sympathy with modern scientific theories, and may even
think them ridiculous—as, I daresay, many people do.
It is difficult to school ourselves to treat the physical world as
purely symbolic. We are always relapsing and mixing with the
symbols incongruous conceptions taken from the world of
consciousness. Untaught by long experience we stretch a hand to
grasp the shadow, instead of accepting its shadowy nature. Indeed,
unless we confine ourselves altogether to mathematical symbolism it
is hard to avoid dressing our symbols in deceitful clothing. When I
think of an electron there rises to my mind a hard, red, tiny ball; the
proton similarly is neutral grey. Of course the colour is absurd—
perhaps not more absurd than the rest of the conception—but I am
incorrigible. I can well understand that the younger minds are finding
these pictures too concrete and are striving to construct the world
out of Hamiltonian functions and symbols so far removed from
human preconception that they do not even obey the laws of
orthodox arithmetic. For myself I find some difficulty in rising to that
plane of thought; but I am convinced that it has got to come.
In these lectures I propose to discuss some of the results of
modern study of the physical world which give most food for
philosophic thought. This will include new conceptions in science
and also new knowledge. In both respects we are led to think of the
material universe in a way very different from that prevailing at the
end of the last century. I shall not leave out of sight the ulterior object
which must be in the mind of a Gifford Lecturer, the problem of
relating these purely physical discoveries to the wider aspects and
interests of our human nature. These relations cannot but have
undergone change, since our whole conception of the physical world
has radically changed. I am convinced that a just appreciation of the
physical world as it is understood to-day carries with it a feeling of
open-mindedness towards a wider significance transcending
scientific measurement, which might have seemed illogical a
generation ago; and in the later lectures I shall try to focus that
feeling and make inexpert efforts to find where it leads. But I should
be untrue to science if I did not insist that its study is an end in itself.
The path of science must be pursued for its own sake, irrespective of
the views it may afford of a wider landscape; in this spirit we must
follow the path whether it leads to the hill of vision or the tunnel of
obscurity. Therefore till the last stage of the course is reached you
must be content to follow with me the beaten track of science, nor
scold me too severely for loitering among its wayside flowers. That is
to be the understanding between us. Shall we set forth?
CONTENTS
Preface v
Introduction ix
Chapter I. The Downfall of Classical Physics 1
II. Relativity 20
III. Time 36
IV. The Running-Down of the Universe 63
V. “Becoming” 87
VI. Gravitation—the Law 111
VII. Gravitation—the Explanation 138
VIII. Man’s Place in the Universe 163
IX. The Quantum Theory 179
X. The New Quantum Theory 200
XI. World Building 230
XII. Pointer Readings 247
XIII. Reality 273
XIV. Causation 293
XV. Science and Mysticism 316
Conclusion 343
Index 355
THE NATURE
OF THE
PHYSICAL WORLD
Chapter I
THE DOWNFALL OF CLASSICAL
PHYSICS
The Structure of the Atom. Between 1905 and 1908 Einstein and
Minkowski introduced fundamental changes in our ideas of time and
space. In 1911 Rutherford introduced the greatest change in our idea
of matter since the time of Democritus. The reception of these two
changes was curiously different. The new ideas of space and time
were regarded on all sides as revolutionary; they were received with
the greatest enthusiasm by some and the keenest opposition by
others. The new idea of matter underwent the ordinary experience of
scientific discovery; it gradually proved its worth, and when the
evidence became overwhelmingly convincing it quietly supplanted
previous theories. No great shock was felt. And yet when I hear to-
day protests against the Bolshevism of modern science and regrets
for the old-established order, I am inclined to think that Rutherford,
not Einstein, is the real villain of the piece. When we compare the
universe as it is now supposed to be with the universe as we had
ordinarily preconceived it, the most arresting change is not the
rearrangement of space and time by Einstein but the dissolution of
all that we regard as most solid into tiny specks floating in void. That
gives an abrupt jar to those who think that things are more or less
what they seem. The revelation by modern physics of the void within
the atom is more disturbing than the revelation by astronomy of the
immense void of interstellar space.
The atom is as porous as the solar system. If we eliminated all
the unfilled space in a man’s body and collected his protons and
electrons into one mass, the man would be reduced to a speck just
visible with a magnifying glass.
This porosity of matter was not foreshadowed in the atomic
theory. Certainly it was known that in a gas like air the atoms are far

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