Fundamentals of Nursing for General Nursing and Midwifery SN Nanjunde Gowda, Jyothi Nanjunde Gowda
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Introduction to NursingChapter 1

Mastery of content in this chapter will enable the student to:
  • Define the key terms
  • Discuss what is nursing and nursing science
  • Describe scope of nursing
  • List the principles of nursing
  • Appreciate the development of nursing
  • Describe the preparation of nurse
  • Describe the characteristics of a professional nurse
  • Describe how code of professional conduct guide the nurses
  • Identify the role of professional nurse
  • Discuss nurse-patient relationship
  • Identify the function of a hospital
  • Describe the function of nursing service department.
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Florence Nightingale May 12, 1820-1920
Nursing profession has become an epicentric concept in the modern world, with the changing life style within the culture and the thinking of the people it serves as the guiding force for service and for the peace of the society.
At present the world is experiencing major social and political change reflecting in the struggle of the people as they seek to live out their national, political and religious aspirations. But sadly, conflict and violence are frequently the hallmark of these struggles as is evident with the world's ongoing wars, uprising massacres, terrorism and extended civic unrest. The untold mission of the people who died or injured in these conflict seems to be growing as the numbers of refugees and forced migrants.
If nurses are infact professionally committed to those important tenets of human rights, then there is an abundant opportunity to act on these commitments. Nurses can work to promote peace and healthful environment. The challenges, of course, are to find ways in which more nurses can make a greater differences at all levels (Regional, National and International).
Nursing is a helping profession and as such it provides services which contribute to the health and well being of the people. Nursing is a vital consequence to the individual receiving services. It fulfils needs which cannot be met by the family, (or) other individuals in the community or the person himself. The essential components of professional nursing are care, cure and coordination. It deals with the human beings under stress. Nursing is an art (skill, how to work and observe) and a science (body of knowledge of human behavior). Nursing as an art has been practiced ever since the human world began.
Mother's were the first practitioners of the art of nursing and women have always been found to care their children, the aged and the ill. The skills required were passed informally from one person to another.2
Nursing means different to different people today, as it depends on the place you live, the tradition you follow and the practices of nursing in your society. Most of the people still think of nursing as a concept of caring for the sick or assisting the doctor in his treatment and care of the patient, but nursing is much more than this.
Nursing has always been directed at serving the health care needs of the society. Nursing originated with the desire to keep people healthy and to provide comfort, care and assurance.
Modern nursing involves many kinds of concepts and skills related to health and social sciences and with basic science on contemporary issues. Nursing as a profession, is unique because it addresses humanistically and holistically the response of client and families to actual and potential health problems.
As early as 1959, DE Johnson wrote about the science of nursing with several existing definitions. Johnson noted that professional disciplines usually represent applied sciences rather than basic sciences, their goals are to use these inputs into practice. He believes that nursing should be a body of knowledge with the following goals.
  • Preventing illness
  • Promoting and maintaining health
  • Providing comprehensive care.
In 1969, Abdellah described nursing science as “a body of cumulative scientific knowledge drawn from the physical, biological and behavioral sciences that is individual nursing”. She experienced the need for nursing to develop into a highly organized and specialized field of knowledge.
The question what is science was addressed by Jacox in 1974. She described science as a process (research and inquiry) and a product (body of knowledge). She emphasized the importance of experienced knowledge, which can be perceived or verified through the sense of others. She also described that knowledge accumulates through examination of phenomena, concept identification, model building and theory testing. Jacobs and Huether support her view point, that science is a product of created by a process that is directly related. They inferred that the major aim of nursing science was to develop theories, to explain, predict and control nursing practice. In other words, they believe that the purpose of nursing science is to develop knowledge for direct application practically, rather than developing knowledge simply for the sake of gaining knowledge. Each science has emerged from the study of different phenomenon or from unique perspective of observation and interpretation of a specific field.
Six principles of science are still relevant even today. They are:
  1. Science must show certain coherence.
  2. Science is concerned with definite field of knowledge.
  3. Science is preferably expressed as a universal statement.
  4. The statement science must be true.
  5. The statement of science must be logically ordered.
  6. Science must explain its investigations and arguments.
These six principles must be applied for science to be a body of knowledge (product) and a research methodology (process). Nursing, as a profession, is striving to meet these principles today.
Defining nursing is difficult. Very little is known about the nurse in prehistory. One nurse historian writes, “From the dawn of civilization, it seems that nurturing has been essential to the preservation of life. 3Survival of the human race, there fore, is very closely linked to the development of nursing. Nursing should be a caring. The nursing art is that of nursing sick. Please mark, not nursing sickness……. This is the reason why nursing proper can only be taught by the patient's bed side and in the sickroom or word lectures and books are but valuable accessories.
One of the reasons it is difficult to develop clear and concise definitions of nursing is because there is a lack of separation from medicine. The interdependence exists between the two professions, medicine and nursing, and they have developed together throughout history. However, anyone who has been involved in the profession of nursing, for any period of time will be quick to assure that differences exist. Primarily the differences are focused on the major goal of each profession. In general, medicine is concerned with the diagnosis and treatment (cure when possible) of disease. Nursing is concerned with caring for the person in a variety of health-related situations.
Early Definitions of Nursing
Beginning with the simplest definition, a nurse is a person who nourishes, fosters, and protects a person who is prepared to care for the sick, injured, and aged. In this sense “nurse” is used as a noun and is derived from the Latin word, “nutrix”, which means “nursing mother”. Another early use of the word “nurse” was associated with the meaning of a woman who suckled a child, usually not her own– a wet nurse. Dictionary definitions of nurse also include such words as “suckles or nourishes”, “to take care of a child or children”, “to bring up, rear”. With such an origin it is understandable that people generally have associated nursing with women.
A few early nurses wrote definitions of nursing, but it has been over the past 50 years that most of the developments of written definitions of nurse and/or nursing have occurred, following are some of the important definitions of nursing:
Florence Nightingale's (Founder of Modern Nursing) Definition of Nursing
Definition of nursing attributed to Nightingale is “The goal of nursing is to put the patient in the best condition for nature to act upon him, primarily by altering the environment” (1859). It signifies the proper use of fresh air, light, warmth, cleanliness and the proper selection and administration of diet, which is vital power to the patient.
Virginia Henderson's (American Nurse Educator) Definition of Nursing
In 1966, Virginia Henderson, wrote a definition of nursing, stating that, “The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death), that he would perform unaided, if he had the necessary strength, will or knowledge and to do this in such a way as to help him gain independence as rapidly as possible” (1966).
American Nurses’ Association's Definition (1980)
Nursing is the diagnosis and treatment of human responses to actual or potential health problems.
World Health Organization's Definition (WHO)
“Nursing, as an integral part of the health care system, encompasses the promotion of health, prevention of illness, and care of physically ill, mentally ill, and disabled people of all ages, in all health care and community settings. Within the broad spectrum of health care, the phenomena of particular concern to nurse are individual, family and group responses to actual or potential health problems”.
These human responses range broadly from health restoring reactions to an individual episode of illness, to the development of policy in promoting the long-term health of a population.4
‘Within the total health care environment, nurse share with other health professionals and those in other sectors of public service, the function of planning, implementation and evaluation, to ensure the adequacy of the health system for promoting health, preventing illness and caring for ill and disabled people’.
Scope means the breadth of opportunity to function or range of activity.
The scope of nursing can be characterized by:
  1. Education opportunity
  2. Service opportunity; can be divided into—
    • – Opportunities in clinical areas and
    • – Opportunities in educational institutes as clinical instructors.
Educational Opportunities at Present
Educational opportunities at present available to prepare nurses to function at various levels of the health care delivery system in the country.
  1. Auxillary Nurse Midwives (ANMs)/Multipurpose health workers MPHW (F)s, 1½ year training program.
  2. Diploma in General Nursing and Midwives, 3 years and 6 months program (GNM).
  3. BSc Nursing Basic, 4 years program.
  4. Postcertificate and postgraduate courses:
    • – Postcertificate BSc nursing, 2 years program
    • – Postcertificate diploma in clinical specialities like, nursing education and nursing administration. 1 year course available in some states only because nursing education and nursing administration submerged with BSc nursing program.
  5. Postgraduate education; MSc nursing education. In 1969 MSc nursing program was started in CMC Vellore, affiliated to Madras University.
  6. M Phil Program: To strengthen the research capabilities of nurses M Phil program started in October 15, 1986.
  7. PhD Program for nurses started in few colleges from 1990 onwards. Psychiatric nursing PhD program also started in NIMHANS, recently. PhD is offered in Sri Ramachandra Medical College and Research Institute, Perur, Chennai and Vinayaka Mission Institute in Tamil Nadu, RAK College of Nursing New Delhi, College of Bursing Mahe, PHI Chandigarh and many other institutes.
Service Opportunities
In both government and private sectors:
  1. Auxillary Nurse Midwives (multiple health workers)
  2. Staff nurses
  3. Senior staff nurses on promotion
  4. Nursing superintendent Grade I, on promotion
  5. Nursing superintendent Grade II, on promotion
  6. District health nurse supervisor, on promotion
  7. Asst joint director of health and family welfare services, on promotion.
In Educational Institutes Job Opportunities
In both government and private sectors:
  1. Clinical demonstrator
  2. Clinical instructor
  3. Asst lecturer
  4. Nurse tutor
  5. Senior nurse tutor, on experience
  6. Lecturer
  7. Senior lecturer, on experience
  8. Asst professor, on experience
  9. Associate professor, on experience
  10. Professor/Principal, on promotion.
Principle is a general truth or selected rule of action, as a guide to action. The objectives of the student nurse are to acquire knowledge and understanding of the basic principles underlying nursing techniques.
Nursing involves many principles from basic sciences, applies these principles to nursing procedures. The following are the basic nursing principles:
  1. Safety
  2. Comfort
  3. Resourcefulness
  4. Therapeutic effectiveness
  5. Good workmanship
  6. Individuality
  1. Safety: A state of being safe (physical and biological), the state of not being dangerous, the nurse's ability to keep or make safe, while providing care. Safety is more important, the way nurse's care for the patient, being in the group makes client feel more confident.
  2. Comfort: The state of being free from pain, suffering or worry, feeling at ease and live in comfort. Nurses will do everything for the comfort of the patient, relieve pain, relief from discomfort (e.g. when patient is not able to pass urine nurse will take measure to make the patient to pass urine or empty the bladder), thus patient will get comfort.
  3. Resourcefulness: The ability to find quick, clever and efficient way of doing things, to provide with resources. Inadequate resources must be properly resourced.
  4. Therapeutic effectiveness: Therapeutic relationship is a helping relationship. Nurses are helpers and clients are those seeking help. It is focused on the client and has a specific purpose, which clients feeling, thoughts, values and culture on achieving the client goal, e.g. observe the effect of therapies given to the patient.
  5. Individuality: It is the characteristic that belongs to a particular person or thing and that makes them different from others. It is a performance of striking individuality. The nurse should consider individuality of each client while calling (by name) or doing nursing procedure, planning nursing care and identifying the needs and problems.
  6. Good workmanship: Nursing is an art (skill, how to work), has been practiced ever since the human world began. Nurses expecting human creative talent while providing care. Patient should be made comfortable, the surrounding kept neat and clean, etc. which shows the good workmanship of nurses.
Nursing in Ancient Times
Nursing is one of the oldest arts. There is always has been helplessness of one sort or another and to a greater or lesser degree, the suffering people have needed care and disease in some form due to intention 6or ignorant disregard of natural laws has always been present in the world. The great, universal mother instinct has met these emergencies by what we call “Nursing”.
Nursing History
Nurses need a foundation of general history on which to base an understanding of nursing history. One needs to have in mind some picture of the times, in which events and changes in nursing took place.
Care of Sick among Primitive People
The lowest savages have a certain amount of nursing knowledge and skill. Much of this knowledge is instinct similar to that of animals. All men doubtless posses these instincts until they lose them by indulgence in the abnormal habits that are the result of so-called “Civilization”.
Nearly all primitive tribes practice massage in some form, with good results, sweats bath, fomentation and other hydrotherapeutic measures are known and used. The first curative services were surgical in character, and attained a degree of perfection before cultural medicine had hardly begun.
Nursing and Medicine
In primitive period, care of the sick, we find no distinction made between nursing and medicine or surgery. Only in very recent times has there been a sharp line drawn between these two forms of service, and even today there is some confusion as to which procedures belong to the doctors and which to the nurse.
Medical Science
During early development, most races came to the conclusion that, many diseases appear extremely mysterious. They caused by some external force or influence and sickness is caused by evil spirits. The medicine man then tried to make the patients body unpleasant for the spirit, in the hope that it would move out. Beating and starving, making dreadful noises, sudden fright, evil smelling or tasting of drugs, etc. were used for this purpose. Remedies to be taken by mouth were often mixed with such materials like cow dung and human urine.
Sickness and Sin
It is an entirely logical step from belief in evil spirit, as causes of disease to believe that it is caused by failure to do something, which God's wished or by a definite moral transgression. Many religions and countries have clearly taught this, from ancient time to until now. Even among highly civilized and intelligent people, the idea is found. We still hear that, “what I do that? I should have this illness and people still look for remedies indeed”.
Medieval Christianity taught that, epidemics of communicable disease were due to the sins of the people and that work of charity or other notable deeds were indicated to stop them.
The First Hospitals
Since religion and medicine were united so early, it followed naturally that the first hospitals were connected with temples or places of worship. Some of the institutions, which have been called hospitals, were merely houses for the sick, which had come to pray or offer sacrifices to God.
Egypt and Babylon
The early medical history of Egypt is the oldest, dating from 2700-1550 BC, which was written by a surgeon called, Imhotep. He evidently learnt anatomy by dissecting human bodies. He devised splints, bandages 7and adhesive tapes, and he used some form of surgical stitching. He is the first author, who speaks of the brain and recognized that it is the central of the body.
In both Egypt and Babylonia (present Iraq), the custom is to lay the sick in the streets, and there were laws requiring that the passers by should give them the advice, with their own experience.
The ancient Persians (present Iran), had houses for the sick, which are poor, and were looked upon by slave boys and girls.
Medicine in Egypt reached a surprisingly advanced stage of knowledge. From clinical observation, they learned to recognize some 250 difficult diseases and to treat them. They developed a number of drugs and procedures, including surgeries. However, Egyptians lack of knowledge regarding normal and pathological physiology limited their theories. Women in Egypt had no carrier, but had some freedom. A mother had position of authority. Women of high rank become priests in the temple.
In the old Hindu villages, there were hospitals for the cure of sick travellers and medical specialists were appointed to them. In Ceylon 5th century before Christ, one of the kings established a hospital; King Ashoka built eighteen hospitals in North India. These public hospitals were also school of medicines. The attendants in them were men and were evidently called nurses. The nurse must be cleaver, devoted to the patient and pure in body and mind must know how to compound drugs.
Between 700-600 BC, that time Sushruata brought the practice of surgery and the Charaka the famous physician were the famous member on the ancient Hindu system known as the Ayurveda. The Vedas, the sacred book of India, stated about the medical treatment, major and minor surgery, bandaging, poison and their antidotes and drugs. Inoculation against small pox was in use among the Hindus from time immemorial. Drugs to produce insensibility to pain were used probably opium and cannabis. Prevention of disease became a matter of first importance and hygienic practices were adopted and cleanliness of the body is considered as religious duty. Doctors and midwives were to be trustworthy and skillful.
China had a well developed civilization long before the civilization era, and cultivated medicine and surgery as honored calling. China had a famous “Father of Medicine”, is Sen Long, who was greatly honored in the Hondgnalty (200 BC-200 AD). Eminent physician and surgeons are passed on to Korea and Japan and became the foundation of their practice. Today, Europe and America occasionally announce a discovery, which was based on old Chinese practice. Unfortunately Chinese progress was hampered by the belief of the common people. They believed that the disease was due to evil spirit in the patient and that it might enter into any one, who touch the sick person, thus the nursing was impossible.
As far back as 1134 BC, there was an Epidural in Greece, a temple to Alklepios, the God of healing. It was a house for those who come to pray to the God, and was a hospital only in the sense that the sick were cared for in it. The God was expected to appear in dreams and prescribe miraculous remedies.
The Greeks did not feel it worth while to care for any illness, but those considered curable. Persons hopelessly ill were often left to die in the streets. Special buildings were created in 170 AD for these patients. These are regarded as the first European hospitals.
Hippocrates the Greek, who lived about 400 BC, is called the father of medicine. He set forth principles, which have governed the practice of medicine up to the present time. He taught that disease was not due to demons or fate, but to the breaking of natural laws. He urged careful observation of the sick and taught the meaning of posture, expression breathing, etc. He also taught that fever cases should have fluid diet 8and to advice cold sponging. He explained the necessity for clean, smooth bed linen, and mouth washes to the sick. Most of these things we regard as modern nursing methods.
Hippocrates Oaths
Hippocrates approach to health care summarized in Corpus Hippocratism, nearly parallel the teaching of professional nursing today. The writing of Hippocrates refer to procedures that would be undertaken in modern hospitals by nurses but do not refer to a nursing vocation as such.
Hippocrates taught what we today call the professional loyalty to the member of ones own craft the attitude toward one's work which carries with it a special sense of obligation to those dependent upon one's service. The Hippocrates oath, still used by medical collages at graduation is a fine expression of the spirit. The so called Florence Nightingale pledge for nurses is modelled after it.
The Romans knew many of the principles of sanitation. Julius Caesar, in first century BC, was the first states man to recognize teaching of hygiene and he had a regular medical service in his army. Roman's medical knowledge came from Greece. Nursing was done by women and old men of good character.
In Roman ruins found in Switzerland They were discovered many nursing utensils, enema apparatus, tubing rectal tips and ointments, etc.
Early Christianity and its Influence on Nursing
The coming of Christ brought into the world a new aspect of religious teaching. Kindness to one's fellows was not a new idea, and we all know that, even in childhood a certain amount of kindness, sympathy for others is innate.
Real Christianity began to teach and has continued devotion to others, without hope of any sort of rewards, but for the sincere love of God and a desire to be like him. This is undoubtedly the highest motive ever persecuted to mankind.
Beginning in the first century AD, the early Christian church and the teaching of Jesus Christ expressed succur to orphans, the poor, travellers and above all the sick. The Christian tendency to exact women to a position enhance to that of man, and to give her a place in the world, outside her home.
The first large Christian hospital in the strict sense of the word was probably in Baseless at Caesarea in Palestine, founded in the years 370. Other Christian hospitals were at Cappadocia in Asia Minor, and at Alexandria in Egypt. As Christianity spread to Rome, its good work went with it and in the early centuries there were Christian hospitals as far well as Aries in the South France.
Important Dates
5000–4000 BC
Egyptian medicine
3000 BC
Beginning of Chinese medicine
2000 BC
Babylonian medicine
1200 BC
Vedas written in India
400 BC
Hippocrates the Greek, “Father of Medicine”
250 BC
King Ashoka and the best era of medicine in India
Modern Medicine and Hospitals
During the eighth to the tenth centurys magnificent hospitals were constructed throughout the modern world. They were staffed by Physician superiors to any in the world, because of knowledge gained and preserved 9from their Greek counter parts. One well endowed hospital was in Cairo and was a prized target that, the Crusaders tried very hard to destroy. Physiology and hygiene were studied by Arabian scientists.
Nursing Brotherhoods
Fully one half the nursing of medieval times was done by men, since it was thought improper for women to nurse a man, who is not a close relative. There grew up many religious orders of men that included nursing among their other duties. Some of these are the Brothers of St Antony, Brothers of Holy Spirit, who lived early in the 13th centuries, and gave up all his wealth and social position. He is said to have been a man of boundless pity and charity.
Related Orders
There were a number of orders that included both men and women, such as the brothers and sisters of charity.
Influence of the Crusades on Nursing
The Crusades were Christian military expeditions to recapture the holy land, where Jesus Christ had lived from inhibiting Muslims. The Crusades began shortly before 1100 and lasted until almost 1300. In the year 1244, about 19000 hospitals existed through out Western Europe. This large number was due to the spread of leprosy. For a thousand year after Christ, there were no attempts to organize nursing. But as the middle age advanced, three type of organization developed. These organizations were the military orders, regular orders (religious), and secular orders.
Early American Hospitals
During the late 1700 and the first decades of 1800, definite land marks were established, namely the big general hospitals in Pennsylvania. The Philadelphia dispensary established in 1786 was the Governor of the modern out patient department and clinic for ambulatory patients. It apparently was so successful that the idea soon spread to other early American cities. Nursing orders in eighteenth and nineteenth century America, such as the sisters of mercy, the sisters of Holy cross and the Irish sisters of mercy, established hospitals and practiced high standard of nursing at that time.
The Renaissance
In the early 1300, great revival of learning and art developed in Italy and spread elsewhere through out Europe. This period is referred to as the Renaissance. One of the causes for Renaissance was a bubonic plague, epidemic that devastated the Western world from 1347-1351, killing 25-50% of European population.
As a result of travel and mixing of people with other lands men became more independent and new ideas brought about advance in many areas. New ideas on art, architecture and literature were developed. The invention of printing increases of medical books. Forerunners of the great medical development of this period were (1) Leonardo Da Vinci (1452-1519), with his anatomical studies and drawing remained classic. (2) Am braise Pore (1510-1590), a military surgeon wrote a book on natural history in general and surgery in particular. During this period, nursing reached high level of organization and efficiency in religious and military orders.
Beginning of Modern Science
William Harvey discovered circulation of the blood.
Thomas Sydenham (1624-1689) was the first person to set the example of true clinical methodology. William Gilbert of Rochester introduced the word electricity. Newton invented Calculus and the Law of 10gravity and Boyle introduced Atomic theory. Thus hundreds of observations and discoveries, which often in the most unexpected way gained practical importance, the foundation for sciences were established. All these developments had an impact on nursing, perhaps not immediately but in subsequent eras, as nursing developed into a science and a protection using these theories as foundation for practice.
The Reformation
The reformation began in the early 1500s. Nursing to its lowest level in those countries, where the Roman Catholic organizations were upset by the reformation.
Oppression of women has a long history and indirectly thwarted any advancement of the nursing profession for centuries. Nursing existed in a low and dismal state, without organization and without social standing. Nurses are considered as the most menial servants. They frequently worked 24-48 hours at a time and their pay was insufficient to support them. The future for these women looked black.
Industrial Revolution (1700-1800)
Women with social compliances and character continued to struggle against the oppression of women during this time.
Emancipation of Women
The American Revolution was against British; as a result, the revolution had an impact on women: which helped with boycotts, stepped into jobs, when men were scarce, organized care for the sick and wounded soldiers.
The American ethic has had its impact on nursing as well and served as the foundation for a need to be doing something. Many nurses today remember the time they spent fulfilling menial labor tasks.
The model of nursing in Germany and to some extent grew as to fit into existing society and system.
When women were recognized equally before the law in decision-making (voting), new opportunities for education opened as early in the nineteenth century. It was difficult for women to obtain an education except through private tutoring. Such education was expensive and available only to few privileged. Florence Nightingale was educated by her father and by travel and social contact. At that time there were no colleges.
The dominant figure in the development of organized nursing is Florence Nightingale. At that time she made her mark in history. Society has changed to the point that holistic scene amenable to a new profession.
Early Life and Education
She was born on May 12, 1820 to wealthy British parents travelling in Italy. Named for the city in which she was born, young Florence never quite fit the mold of a Victorian lady. She was well educated in literature, music, drawing and the domestic arts. A women of her social standing was expected to marry and devote her life to her family, entertaining, and cultural pursuits. However, she felt an early calling to serve, and refused to marry. When she attempted to go to work as a nurse, her horrified family repeatedly opposed her. In those days, hospitals were often dirty and dark and nurses were untrained, sometimes drunken women. Finally, at age 33 she was able to obtain some minimal training and begin her career.11
Experience at Kaiserswerth (Institute at Germany)
During one of her journey, Florence paid a visit to Kaiserswerth, under the direction of Reverend Pastor Elicatner, embracing the support and love of a hospital, Inland and industrial school.
Crimean War
The Crimean war won Nightingale title of ‘lady with the lamp’. The British, French and Turkeys were fighting with Russians, near the Black sea and Crimean Peninsula. There were serious problems with the handling of sick and wounded soldiers, especially British and leaders were needed to organize an effort to save lives of the wounded and sick. 38 nurses were recruited, condition under which these nurses worked were atrocious, even the simplest means of healthy living were absent. At first, Nightingale and the nurses do not had the respect and confidence of the physicians, which required time and evidence of what the nurses could do. But Nightingale insisted that nurses not to give help unless they were asked. Finally the nurses were asked for assistance by the physicians.
Once the Nightingale and her nurses were set to work, hospital was established. Florence divided her time between administration and personal attention to patients. She became famous for her night rounds. It was during her night rounds with her lantern, that she made her tour of inspection with friendly word, smile for others. She inspired a feeling of comfort by sympathizing with the patients. Nightingale's night rounds are perhaps the most famous, which made reference to Florence Nightingale as ‘the lady of the lamp’.
Her changes revolutionized British military medical care, increasing standards for sanitation and nutrition and dramatically lowering mortality rates. While visiting the front lines, she became ill and never really recovered.
Nightingale continued to have an influence on standards of nursing care and training. In 1859, she helped to establish the first Visiting Nurse Association and in 1860, she established a school that became a model for modern nurses training, at Saint Thomas Hospital. She published book notes on nursing to state what it is and what it is not. Graduates of nursing school went to various countries of the world to practice nursing. Many of them became head nurses in such countries as Germany, Norway, Sweden, Scotland, Canada, US, India, South Africa and Australia.
She was considered an expert on the scientific care of the sick and was asked by the United States for her advice on caring for the wounded soldiers of the Civil War. Through correspondence and reports, she continued her influence throughout her last years. She was the first women to receive the British Order of Merit. In 1907, the International Conference of Red Cross Societies listed her as a pioneer of the Red Cross Movement. She died in 1910 at the age of ninety.
As Nightingale demonstrated, statistics provided an organized way of learning and lead to improvements in medical and surgical practices. She also developed a Model Hospital Statistical Form for hospitals to collect and generate consistent data and statistics. She became a Fellow of the Royal Statistical Society in 1858 and an honorary member of the American Statistical Association in 1874. Karl Pearson acknowledged Nightingale as a “prophetess” in the development of applied statistics. (Written by Cynthia Audain, Class of 1998 Agnes Scott College).
A nurse is a person (male or female), who has completed a program on basic nursing education and is qualified and authorized in his/her country to render the most responsible service of a nursing nature, for the promotion and maintenance of the health, and for the prevention of illness and the care of the sick.12
The professional nurse is a health care worker, a graduate from a recognized school who is identified by law as a registered nurse whether graduated from a baccalaureate (BSc) or diploma program.
Nurses as other human beings, have certain emotional needs. Preparing them to pursue nursing training their emotional needs are depending on personality traits, family, society, traditional background they belong and posed with affection, belongings and their needs must be met, if the student is to adjust into a well integrated personality, who can deal with many difficult situations in day-to-day practice.
Nursing student will be helped to develop well integrated personality, providing opportunity to explore and experiencing themselves. A program of nursing education which provides continued training by imparting knowledge. Theory and clinical experience allow the student to analyze nursing care situation and process and apply basic principles from anatomy, physiology, sociology, psychology, medicine and other modern sciences to her nursing care in clinical situation. Nursing student can be helped to develop their skills or to bridge the gap between theory and practice.
The nursing student will be enlightened to maintain individual dignity of every person without distinction as to race, nationality, occupation and color. The nursing student will be helped to develop good communication towards patient and patient family and also to develop good therapeutic nurse patient relationship. Nurse's overall attitude should reflect the profession as well as it should be beneficial for patient recovery.
The nursing student should be provided the foundation upon which, morality and character are built. Good character is important for a nurse. Right conduct in innumerate situations can be expected. Only if the nursing student has developed a sound moral character, and such can be developed only of an adequate understanding and habitual application of proper moral standardize, right consciousness is an important factor for the nurse to develop.
A nurse with a lax or hordered conscience would do much harm to humanity. The purpose of nursing education is to prepare future nurses and nursing education, in order to provide a systematic development and training of intellect, so that its purpose will be served for preparing true professional nurse in the fulfilment of her function in nursing. The nursing student, who meets the requirements for giving care means, that she has a sound understanding and skill in effective human relationship, which takes place within interpersonal human relationship. She also should know the background of each patient, his religion, racial culture, economic, educational background and recognize that health knowledge and habits are influenced by these backgrounds.
Further she should know how to adopt her nursing care and health teaching to the needs of each patient, when prejudices and superstitions are present to treat them with tolerance, sympathy, fact and understanding.
Since all education is the out growth of philosophical beliefs, nursing education is the application of these fundamental beliefs to the field of nursing education. This philosophy will determines the selection of students, the preparation of faculty, the development of the curriculum, attitudes towards patients and community, the personal life, professional growth of every member of the student body and faculty.
Philosophy has been derived from two Greek words, ‘Philos’ means love, ‘sophy’ means wisdom. It is the love and searching for wisdom and truth. As per Handerson Philosophy, is a search for comprehensive views of nature, an attempt at a universal explanation of nature of things.13
It is a living force, a way of life, an attitude towards life and a search for truth and reality. It is a speculation about the nature and value of things. Plato said, he who has a taste for every sort of knowledge and who is curious to learned never satisfied, may be just termed as philosopher.
Questions of Philosophical Inquiry
What is life?
What is man?
Where he came from?
What is man's destiny or goal?
Philosophers try to answer these questions according to their own mature reflection and thinking.
A philosophy of nursing education includes beliefs and values with regard to man in generally and specifically man as the learner, teacher, nurse and the client and the belief about health, illness, society, nursing and learning.
Philosophy of Nursing
A philosophy of nursing includes basic premises about the nature of nursing, about the goals of nursing, about to right to health and concludes obligation for maintaining health and about the role of nurses in health care systems in society. Nurses offer guidance to help individuals maintain health. Nurses are partners with physicians in promoting health in preventing disease and in managing patient care. Care is considered as one of the important values expressed in philosophy of nursing. Nurses are expected to synthesis the knowledge from natural and behavioral science and from nursing science and to use knowledge in making decisions to meet basic needs of individuals that are immediate in nursing situations.
The basis for the practice of professional nursing is knowledge, the activity is guided by the intellect and its intellectual activity is applied in the practical realm. Nurses are expected to possess intellectual skills, interpersonal skills and technical skills.
Core Values in Nursing
A person entering nursing, has a set of personal values that guides his/her actions. These values are the result of personal choice and are learned over times.
Values essential to the practice of professional nursing are:
  1. Aesthetics (qualities of objects, events and person that provide satisfaction).
  2. Altruism (regard for the welfare of others).
  3. Equality (having the same right of privileged).
  4. Freedom (the ability to exercise choice or action).
  5. Human dignity (inherent worth of an individual).
  6. Justice (fair treatment through the upholding of moral and legal principles).
  7. Truth (faithfulness to fact or reality).
The professional nurse must have certain qualities and characteristics, in order to be considered a good professional. These are:
  1. Nurse must be mature physically and emotionally (good physical and mental health).
  2. Nurse must have an up to date knowledge (general and special).
  3. Nurse must keep herself clean, tidy and well groomed.
  4. Nurse must be dependably clever, gentle, sympathetic (sharing), cheerful alert, tactful, kind and honest.
  5. Nurse must inspire confidence in others and in herself.
  6. Nurse must be intelligent.
  7. Nurse must be open minded, cooperative, responsible and able to develop good interpersonal relations.
  8. Nurse must be a good leader.
  9. Nurse must have positive attitude towards caring.
  10. Nurse must be truthful efficient in technical competence.
  11. Nurse should be responsible to family, society and not particularly devoted to the patient.
  12. Nurse should have self-belief towards human care and cure.
  13. Nurse should convey cooperative attitudes towards co-workers. In turn they will develop greater respect for the nurse, who is courteous and considerate.
A profession is an occupation with moral principles that are devoted to the human and social welfare. Professional nursing is a service devoted to the promotion of human and social welfare.
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Nursing as a profession
Is nursing a profession? There is never a definite answer to this question, as nursing continues to develop in three primary areas, education, practice and research. It needs more and more criteria, for it to become a profession. They are:
  1. Based on social and scientific principles; have its own body of knowledge.
  2. Have a strong scientific base (academic and theoretical).
  3. Have a strong service orientation in response to the social needs of human and social welfare.
  4. Have a code of ethics.
  5. Have a professional organization to that sets standards.
  6. Conduct ongoing research to enhance the body of knowledge, and to improve service to society.
  7. Have autonomy (self governance).
Ethics is a term with many meanings. Simply stated ethics is concerned with how people ought to act and how they ought to be in relation with others. Ethics does not just describe how things are, but rather is 15concerned with establishing norms or standards for how human life and conduct should be.
To become mature professional, who are able to participate effectively in the ethical dimensions of their practice, nurse must continue to develop a strong sense of their moral identity, seek support from available professionals and expand their knowledge and skills in the area of ethics.
The basic term in ethics includes beneficence, non-malfeasance, justice, fidelity, and autonomy.
Beneficence: Taking right action or providing good care to client or the act of a nurse should benefit the client. Do well to the patient, act in the best interest of the patient.
Non-malfeasance: Is the avoidance of harm. Nurses not only doing good to the patient, but also they should have equal commitment to do no harm to the clients.
Justice: Refer to fairness. Health care providers do justice while providing care. E.g. Provision for resource distribution like provision for admission, discharge planning, supply of proper medication and implants.
Fidelity: Refers to keep promises to reduce the discomforts, i.e. if client complain of pain abdomen, health care providers/nurse offered the pain medication, fidelity encourages to monitor client response to pain, revision of plan of care if necessary.
Autonomy: Refers to independence, respecting others right to determine course of action, include in all aspect of care. In other words, nurses respect the patients “Bill of Rights”. Clients are responsible for their own care in matter of health and illness.
Health is influenced by an array of demographic, socioeconomic, political and environmental factors that are constantly changing. Most countries are currently seeking to adopt health structures and policies that will use resources more efficiently and encourage behavior that promote health. Therefore, reformed health system needs health care personnel, who can provide the essential elements on primary health care effectively, within the cost constraints. This requires the effective use of human resources, intrasectoral cooperation and partnership between individual and communities. Nursing practice is a valuable resource for health. It was constantly shown flexibility in its response to demographic, economic and social changes. As a result of these changes, nursing practice is now a key component of health care in every setting.
Maintaining Standards of Practice
Most nurses have learnt basic theoretical concepts and clinical skills in their nursing education. It is the responsibility of the nurses, the employers, the associates and all the educators to assure the updating of these abilities by continual education and by other means. The administrative and managerial skills are frequently necessary, as these abilities must also be continuously improved.
The code recognizes that in many situations reality may impede in carrying out nursing skills at the highest level; as stated in the set standards.
Examples of such Situations are:
  • Shortage of supplies or Inadequate supply. (Medicines/materials/manpower)
  • Unsuitable facilities or Insufficient personnel.
  • Language barrier or Geographical isolation, etc.
Delegating and Accepting Responsibilities
The nurse uses judgment in relation to the individual's competence when accepting and delegating responsibilities. The nurse faces daily situations in which she is asked to carry out certain functions for which she feel, inadequately prepared by her colleagues, nursing administration, physicians, patients and families. This requires a more competent person. If it is not available then it is a question of convenience or the lack of knowledge of the person making the request.
The nurse may be expected to take over activities that could be done equally well by a person with less preparation, thus under utilizing the nursing competencies. In delegating activities or functions to others, the nurse must give full consideration to the dangers that are implicit in the assignments beyond the individual's competence and potential.
Cooperative Relationship
Under this heading, ‘nurses and co-workers’, the code of nurses states that: the nurse sustains a cooperative relationship with co-workers in nursing and in other fields.
Implications for Nurses
  1. The relationship between nurses and other workers often leaves much to be desired.
  2. In nursing, the traditional hierarchy often is interpreted as “there are people who give the orders and there are those who carry out orders”.
  3. In a truly cooperative relationship, especially between the staff and the administration, there should be, “give and take” all around. This may be interpreted as “harmonious relationship”, but truly, professional nursing calls for a true colleague relationship on information sharing and decision-making among nurses, doctors and other workers involved in certain aspects of the patient care and well being.
The code states that the nurse, acting under the professional organization, participates in establishing and maintaining equitable social and economic condition in nursing.
Implications for Nurses
  1. In the past decade International Council for Nurses (ICN), has promoted improved salary and better working conditions for nurses.
  2. The council has helped member associations to develop programs to enhance better conditions for nurses in their countries, which are equitable to those persons who have similar qualifications and responsibilities.
  3. In the international level, ICN has worked with WHO and the International Labor Organization (ILO), to prepare a document which hopefully makes a major impact on recruiting and retaining nurses in the work force.
  4. The change in the status of the nurse since the modern times are from a single women living in a nursing quarters to a married male or female nurse, required a major change in the employment conditions.
Respect for Life
The code for nurse states that the nurse should “respect life”. This statement was replaced by “preserved life”, as the change was made in the light of modern technology which enables the continuation of vital 17life functions by mechanical means, in situations where the irreversible damage would cause immediate death without artificial intervention.
Implication for Nurses
The question of respect for life is deeply routed in religion, culture, law, nursing, medicine, philosophy and other disciplines.
Each nurse holds strong faith and belief on these concepts. There are three kinds of situations, in which the nurse may face with these issues. They are, heroic measures in irreversible terminal cases, preventing conception or interrupting pregnancy and decision related to respect for life, must be made by a qualified and authorized group and not by a single individual.
Infants are some times born with defective bodies or minds. Many times these defects can be seen at birth. These infants have a very short life span and sometimes long. The quality of life depends on the nature and extent of the deformity and the infant's culture. A conflict exists between people for the appropriate care on these infants. Nurses also face such conflicts. They may follow the direction of others or follow institutional policy.
The code of nurses states that the nurse provides care, promotes an environment in which the value, customs and spiritual beliefs of an individual is respected.
Implications for Nurses
Care may meet certain individual needs, namely
  1. Biological needs
  2. Therapeutic regime
  3. Provide emotional support
  4. Health education
Environment Includes
Physical setting of an individual as his home, school, place of work, health center, clinic, hospital and the psychosocial atmosphere such as interpersonal relationships, behavioral norms, socialization process, etc. the nurse cannot control or direct the total environment.
Utilizing the available resources and developing resources which are not available.
The nurse is the care giver who has extensive contact with an individual and the family. She is then able to assess the values, beliefs and the customs to incorporate her knowledge to them by directing the nursing care of other therapists.
Note: Recognition and respect to these values, customs and beliefs of an individual does not mean actively accepting them, but it should not cause any conflicts with the nurse's basic beliefs or values.
The code of nurses states that the nurse holds in confidence personal information and judgment in sharing this information.18
Implication for Nurses
Patients under stress frequently reveal thoughts and ideas which they would not want others to know. Later, they may regret or even fear of having made such confidences. Sometimes, these revelations may relate directly to the illness or affect the recovery process or they may have an indirect effect on the patient or others within the patients family or friends, hence the nurse should use her judgment to determine when to share information.
One of the rights of man is the right to knowledge about himself, in the case of a patient knowledge of a diagnosis, the treatment, the prognosis or other facts may help or hinder in his care. Both the physician and the nurse must be in a position to give or withhold information. The patient or his family may request such information. Sometimes those give care, relate information voluntarily.
The code indicates that the nurse's primary responsibility is to meet the needs of the people those who require nursing care.
Nursing Code of Professional Conduct
The code is subject for regular review and changes, any recommendations for change and improvement would be welcomed.
  • Recognize that an image problem does exist and that each individual nurse has a responsibility to improve the profession's (al) image.
  • Strengthen involvement in professional organizations collectively.
  • Become politically active and politically knowledgeable.
  • Write and submit feature stories on nurse for local media.
  • Demand that nursing authors be considered for editing health columns.
  • Provide technical assistance to the media.
  • Provide ongoing public service announcement. Focus attention on well defined services catered and controlled by nurses: ‘case management’.
  • Create public forums, spend a day with a nurse,
  • Have nurse's present education talks at public hall.
  • Establish a speakers bureau for local elementary, junior and high school.
  • Improve the community image, volunteer for community sponsored activities.
  • Revise and update nursing career literature especially books at school and public libraries that introduce the profession to a prospective nurse.
  • Become more active as authors.
  • Monitor the “get well” cards found in the hospital, gift shops and in local card shops.
  • Any adverse portrayal of nurses should be protested verbally or in writing.
  • Establish schools of nursing as research and information centers for people experiencing critical health care issues, e.g. Aids information center.
  • Increase staff involvement in scholarly activities such as research.
  • Never allow the nursing profession to be potrayed as physicians hand maidens, but to be potrayed as physicians’ peers.
  • Be self-confident, this commands respect.
  • Be positive, complaining does not create a good impression and rarely solves any problem.
  • Increase visibility; make sure that clients/families know that the nursing staff is responsible for 24 hour care.
A role is a pattern of behavior expected from an individual in specific social situations. Role of the professional nurse means different roles a professional nurse perform in her day to day practice. In practice several roles often coincided. They are:
The caring or confronting role of the nurse has traditionally included those activities that preserve the dignity of the individual and those often referred to as the, “mothering actions”. In nursing, caring is the role of human relations. The nurse supports the client by attitude and by actions that show concern for the client's welfare and acceptance of the client as a person and not merely a mechanical being. Caring is central to most nursing interventions and an essential of the expert nurse.
Effective communication is an essential element of all helping professions, including nursing communication which shapes the relationship between nurses and clients, colleagues and other health care providers. Communication facilitates all nursing action. Like the nurse communicates to other health care personnel. The nursing intervention is planned and implemented for each client. Planned nursing interventions are written on the clients care plan and once the interventions are implemented, the nurse documents them on the client's record.
A teacher helps the student to learn. It is an interactive process in which specific learning objectives or desired behavioral changes are achieved. The focus of behavior change is the acquisition of additional knowledge or technical skill.
Counseling is the process of helping a client to recognize and cope with stressful psychological or social problems, to develop improved interpersonal relationship and to promote personal growth. It involves emotional, intellectual and psychological support. Nurse counsels primarily healthy individuals with normal adjustment difficulties but the focus is on helping the person to develop new attitudes, feelings and behavior rather than promoting intellectual growth. The client is encouraged to look into an alternative behavior, to recognize the choices and to develop a sense of control. The nurse counsels clients who need to decrease activity levels, like stop smoking or to lose weight, accept changes in body image or cope with impending death.
Client Advocate
Advocacy involves concern for and defined actions on behalf of another person or organization to bring about a change. A client advocate is an advocate of client's rights. Advocacy involves promoting what is best for the client by ensuring that the client's needs are met by protecting the client's rights.21
Change Agent
A change agent is a person or group who initiates changes and assists others in making modification by them or in the system. Marriner Tomey 1992, describes a change agent as one who identifies the problems, assesses resources, determines appropriate helping roles, establishes and maintains helping relationship, recognizes the phases of the change process, and guides the client through these phases. The promotion of change is an essential component of nursing care, by using the nursing process the nurse helps the client to propose, implement and maintain changes that promote the clients health.
Leadership role are applied at different levels, individual, family, groups, communities or the larger society. At the client level, nursing leadership is defined as a mutual process of inter personal influence through which the nurse helps a client make decisions in establishing and achieving his goals to improve the clients wellbeing. Leadership validates the professional nurses’ practice and enhances professional growth.
Management is often confused with leadership. Tappen 1989 defines management as “planning and giving directions, developing staff monitoring operations, giving rewards fairly, and representing both staff members and administrations as needed”. Management therefore occurs within an organizational environment. Leadership by contrast may or may not require delegated authority within a formal organization.
The nurse manages the nursing care of individual's, groups, families and communities. The nurse manager also delegates nursing activities to workers, other nurses and supervisors and evaluates their performance.
The majority of researches in nursing are prepared at the doctoral and post doctoral level, although clinician with master degree are beginning to participate in research activities as part of the advanced practices role. ANA's standards of clinician nursing practice states that all nurses should participate in research based on their level of education, their position and their practice setting. Nursing students must learn to investigate the role of the nurse early in their career to bridge the research-practice gap effectively.
Nurses are creative professionals who want to enjoy their work and achieve success in delivering the very best care to their clients. If properly lead or motivated it can solve even the most complex problems. An empowering work environment is one that brings out the best in professionals concentrating on effective client care systems.
Since the time of Florence Nightingale there have been a variety of nursing care delivery models and methods by which nursing care is provided for clients. The essence of nursing is in how nurses, care for their clients. Care delivery must be effective in helping nurses achieve deliverable outcomes for their clients.
Total Patient Care
Total patient care delivery is the original care delivery model developed during Florence Nightingale time. A registered nurse (RN) is responsible for all the aspects of one or more clients care. The nurse works directly with the client's family, physician and health team members. This model typically has a shift based focus, were continuity of care will be a problem, if the staff do not clearly communicate the client.22
Functional Nursing
Functional nursing first developed in the 1950s during a nursing shortage. It involves the division of tasks with one nurse assuring the responsibilities for certain tasks (e.g. hygiene or other nursing procedures), while the other nurse assume responsibilities for the other (e.g. medication, feeding, etc.). Nurses tend to become highly competent within the tasks that are repeatedly assigned to them. There is a major disadvantage when care will become mechanical and task focused, not client focused.
Team Nursing
Team nursing involves the delivery of nursing care by the staff of various educational preparations. A registered nurse will lead a team made up of other registered nurse.
Nurse assistance are technicians. The team members provide direct client care to a group of clients who follow directions of the team leader. This poses a risk to the assistant personnel who are not prepared to perform all care required by a client.
The team leader coordinates care of the team by communicating with the physician and the other health care personnel by resolving problems met by the team member. Frequently risk exists, if a registered nurse is unable to make ongoing client assessment. The advantage of team nursing is the collaborative style that encourages each member of the team to help each other.
Primary Nursing
The primary nursing model was developed with the aim of placing a registered nurse at the bed side and improving the professional relationship between the staff. The registered nurse selects the clients for his or her case and cares for the same clients during their hospitalization. The registered nurse assesses the clients needs and develops a plan to care and ensure that the nursing intervention is delivered. If there are differences in opinion as to the clients needs then the primary nurses collaborate to modify the plan.
Primary nursing is one of the care delivery model designed to maintain the continuity of care in shifts, or days. It can be applied in any setting. Primary nursing aims at collaboration with other professionals and enhancing the client-nurse relationship.
Case Management
Case management is a care delivery approach that coordinates health care services to clients and their families. A nursing case management model involves a professional nurse assuming responsibilities for client care from the admission to the following discharge.
A case manager may not provide direct care, but they collaborate and supervise the care delivered by other staff members. Case managers may be nurses, social worker or physician. In client care, all members of the health care team work for the same plan.
School Health Nursing
Community based health services are common in school and college campuses. Nursing services include health education, disease prevention, health promotion and sex education. Nurses working in schools may provide acute care on upper respiratory tract infection, influenza and viruses. School heath nurses also make referrals for students and their families.
Occupational Health Settings
Many large companies provide health services to employees in occupational health centers located in the premises. The nurse treats non-emergency acute issues and provides first aid on emergency situations such as heart attack or trauma. The nurse gives emergency care and arranges transportation to a hospital.23
Home Health Care Agencies
A client often needs specific nursing care that can be given efficiently at home and provide home care to client discharged from another institute.
Progressive Patient Care (PPC)
Progressive patient care is the systematic grouping of patients according to the severity of their needs for care, instead of organizing the hospital on the basis of patient's diagnosis, age, sex or economic status. The central theme of progressive patient care is the better utilization of facilities, services and personnel (medical and nursing) for better patient care.
There are five elements incorporated in progressive patient care concept, they are the following:
  1. Intensive Care: The purpose of intensive care is “life saving”. Basically all health care practices are designed to observe and preserve the vital functions of respiration, circulation and elimination. Life saving equipment, drugs and supplies are made available for immediate use at all times.
  2. Intermediate Care: From intensive care unit the patients are transferred to intermediate care units when they no longer need close attention of medical or nursing personnel. Here the patients have the continuity of care which they were receiving at the intensive care unit. Emergency care and frequent observation are rarely needed, they are able to meet their own needs to some extent. Here they learn the technique of ambulation or accept limitations produced by their illness.
  3. Self Care: Patients who have recovered from critically ill diseases or those who are admitted for investigations or therapeutic services are seen in this unit. Most of the patients in self care units are ambulatory. Examples of patients in self care units are post coronary patients, who learn progressive physical activity under close supervision, a diabetic patient who requires frequent lab test, dietary management and adjustment to insulin dosage, etc.
  4. Long-term Care: These units are assigned to patients who are substantially disabled by the effect of disease. For these patients, the period of convalescence will be a long one as they require a course of restorative or rehabilitative treatment for considerable duration. The patients in these units will be partially or totally dependent on the nursing care to carry out their activities of daily living.
  5. Home Care: This is the part of the outpatient program. Home care is benefited by those patients who are ambulatory and who never need hospitalization. If adequate education is given, family members and patient himself can help home care program.
Total Patient Care
Total patient care is a concept that provides the basis for nursing practice. The word total means holistic or whole and is used here to imply consideration of all human needs related to physiologic, psychologic and sociologic needs. The nurse is not equipped to meet all these needs alone but plays a major role in the identification of the needs and the coordination of the services of the personnel, both in and out of the hospital.
The helping relationship between the nurse and the patient (client) is called the nurse-patient relationship. The nurse is the helper and the client is the person being helped.
Basic Characteristics of Nurse-patient Relationship
  1. Nurse-patient relationship is dynamic. Here both the person are active participants to the extent each is possible.
  2. It is purposeful and time limited; this means, there are specific goals that are intended to be met within a certain period of time.
  3. It is focused on the achievement of the client-centered goals.
  4. It requires the active presence of the nurse.
  5. The person providing the assistance assumes the dominant role.
The Importance of Nurse-patient Relationship
  1. It is a central to nursing.
  2. It can be used as a therapeutic tool.
  3. It improves patient's health.
  4. Through this relationship the goals of nursing are achieved.
  1. What is meant by therapeutic relationship?
    The relationship between the nurse and the patient (client) is called therapeutic relationship when the interaction is beneficial to patients.
  2. What is the meaning of beneficial?
    The interaction between the nurse and the patient helps the nurse and the patient to move towards common goals.
Examples of Common Goals (for the nurse and the patient)
  1. To improve the patients physical well being.
  2. To increase the patients independence.
  3. To increase the feeling of worth.
The Nurse's Role
The nurse selects nursing care activities (actions, measures, interventions, managements, etc.), that will move the patient toward the common goal. Achieving the goal will satisfy the patient's human needs.
Steps of Nurse-patient Relationship
There are four stages of nurse-patient relationship.
  1. Orientation phase
  2. Identification phase
  3. Working phase
  4. Termination phase
Orientation Phase
  1. The nurse and the client meet and learn to identify each other by name.
  2. The nurse begins to assess the patient through data gathering as a part of nursing process.
  3. The patient also begins to assess the nurse with various questions in order to learn about the kind of person that the nurse is.
  4. The nurse needs to adopt a warm friendly manner, to smile appropriately and the use of eye contact.
  5. The nurse establishes trust by being honest, consistent in his/her own behavior.
Identification Phase
In this phase the nurse and the patient become better acquainted. Trust is established, the nurse is able to explore the patients underlying needs and the problems to establish goals.
Working Phase
  1. The nurse and the client work together to meet the client's needs as identified during the orientation phase.
  2. The nurse provides support to the patient and work through his problems by his physical and active presence by:
    • – Listening
    • – Showing understanding
    • – Empathy
    • – Setting limits
  3. The nurse helps the patient towards personal growth and independence by providing support.
Terminal Phase
Termination of nurse-patient relationship occurs when the patient has accomplished his goals.
  1. The nurse-patient relationship is a professional relationship.
  2. Never allow your personal feeling to impeded the patient's progress towards independence.
  3. The preparation for termination of the relationship should begin at the initial phase relationship. Otherwise the patient may feel angry, rejected by the nurse or depressed and helpless.
Factors that Help to Promote Successful Therapeutic Nurse-patient Relationship
  1. Encourage patient to talk about his/her feelings.
  2. Use simple language which the patient can understand.
  3. Explain procedures.
  4. Show understanding and acceptance.
  5. Convey warmth and friendly attitude–bothverbal and nonverbal, e.g. greet the patient with a smile.
  6. Treat each patient as an individual, worthy of respect and even consider individual differences also.
  7. Ask related questions.
  8. Maintain silence
  9. Use active listening, which means;
    1. More than just hearing the words spoken by the patient,
    2. Noting tone of voice, body movement, posture, facial expressions, the eyes, etc.
    3. Complete attention to understand the entier message verbally and nonverbally.
    4. Encourage further talk and
    5. Explore unexpressed feelings.
  10. Build trust:
    1. Trust is an essential component of nurse-patient relationship.
    2. It can provide the patient with a basis for learning and growth.
    3. The nurse must work towards developing the patient's trust.
    4. The nurse must be a person who can be trusted.
Barrier to Therapeutic Nurse-patient Relationship
  1. Lack of self awareness.
  2. Acting out ones own conflicts, through a relationship with the patient.
  3. Giving personal information about oneself instead of focusing on him.
  4. Becoming emotionally involved where the relationship is no longer beneficial to the patient.
  5. Feeling that he/she (nurse) is the only person who can help the patient.
  6. Spending a disproportionate amount of time with the patient.
  7. Taking sides with the patient against his family.
  8. Making false promises to the patient.
  9. Labeling the patient with disease, e.g. ‘hysteric’ or ‘schizy’.
  10. Avoiding the patient.
  11. Prolonging the relationship when the therapeutic need for such a relationship no longer exists.
  12. Entering the pseudochem relationship with patient.
Health Care Agencies
Like all social organizations hospitals grew out of necessity. In the past, the hospital has been a place for care of the sick. Today, the hospital has become a center of technical services for the sick and well, inpatients as well as outpatients with greater emphasis on achieving the highest standards of patient care and community health.
The word ‘hospital’ is derived from the Latin word hospitals, which comes from ‘hospes’, meaning a host.
  1. “The hospital is an integral part of a social and medical organization, the function of which is to provide for the population complete health care, both ‘curative’ and ‘preventive’ and whose out patient services reach out to the family and its environment; the hospital is also a center for the training of health workers and biosocial research” (WHO Expert Committee on Organization of Medical Care).
  2. The American Hospital Association (AHA) defines a hospital as:
    An institution with the primary function of providing diagnostic and therapeutic patient services for a variety of medical conditions, surgical and nonsurgical.
  3. A hospital is a health care institution with an organized medical and professional staff, and with permanent facilities that include inpatient beds, provides medical, nursing and other health related services of patients.
Functions of the Hospital (four categories)
  1. Patient Care: Primary function (curative function)
    Refers to any type of care given to patients, by the health team members, like Physicians, Nurses, Physical therapists, Dieticians, etc. It also includes health teaching to patients.
  2. Health Personnel Education: Secondary function (training function)
    Refers to the education of professional and technical personnel, who provide health services, e.g. Physicians, Nurses, Dentists, Therapists, Technicians, etc.
  3. Health Promotion: Secondary function (preventive function)
    An emerging function for the hospital is that of a community health center taking an active role to improve the health of the population it serves. Hospitals as major community health centers can sponsor programs of environmental and occupational health, home care services, etc.
  4. Health Related Research: Secondary function (research function)
    Research that focuses on the improvement of health and/prevention of disease.
Classification of Hospital
Hospitals are classified as follows:
According to the Type of Service
  1. General
  2. Special.
  1. General Hospitals
    They care for patients with various disease conditions of both sexes to all age groups, medical, surgical, pediatrics, obstetrics, eye and ear hospital, etc. General hospitals may contain specialized units staffed by specialized personnel, Renal Unit, Intensive Care unit, Coronary Care Unit, Plastic Surgery Unit and Burn Unit. There may be specialization at Unit level, Neurological, Urological, Orthopedic Units, etc.
  2. Special Hospitals
    They limit their services to a particular condition like, orthopedics, maternity, pediatrics, cardiology, renal, geriatrics, etc.
According to Administration, Ownership, Control or Financial Income
  1. Governmental or Public Hospital
    They are owned, administered and controlled by government. They provide free care, to all patients. They may offer private accommodations for fee-paying patients. The Government Hospitals are guided by Ministry of Health, Director of Medical Education and Family Welfare Services, managed by Medical Superintendent and Nursing Superintendent.
  2. Nongovernmental or Private
    • Proprietary: Privately owned or controlled by an individual or group of Physicians or citizens or by private organization (profit-making).
    • Voluntary: Owned and operated by nonprofit organizations, i.e. temple mosque or church authorities.
  1. According to Size and Bed Capacity:
    Small hospital
    100 beds or less
    Medium size hospital
    100-300 beds
    Large hospital
    300-1000 beds
At the head of any hospital organization there is a governing board or board of directors (Policy-making body), which represents the owners.
Authority for the administration of the hospital is delegated by the governing board to the director or administrator. The administrator is responsible for maintaining standards of service and patient care, established by the board. He is responsible to carry out the functions of the hospital in accordance with 28the philosophy and established policies set by the governing board. He delegates the responsibility for the different departments to the departmental heads, who are specialists in their field. In large hospitals, the administrator has one or more assistants to help with the administration of various departments, one of them for the business management and the other for the professional care of the patient.
A. Professional Health Service Departments
Medical Department
The medical department has within it the various clinical services. They are medicine, surgery, gynecology, obstetrics, pediatrics, ophthalmology (eye), ENT, dental, orthopedics, neurology, urology, cardiology, psychiatry, dermatology (skin), plastic surgery, nuclear medicine, etc. Medical director is a doctor, who has control over all the medical departments.
Nursing Department
The nursing department consists of nursing service and nursing education. The primary purpose of the nursing service is to provide comprehensive, safe, effective and well organized nursing care through the personnel of the department. The primary purpose of nursing education is to raise the standard of nursing service by providing education to nursing service personnel in the hospital.
Paramedical Departments
They include:
  1. Laboratory
    • Pathology Department: The pathology department is one of the largest departments and has the responsibility for making tests and studies on blood, sputum, urine, feces, body fluids and tissues. The following laboratories are usually found in a pathology department.
    • Bacteriology Department: This laboratory is concerned with studies about the bacteria and their toxins.
    • Biochemistry: This is considered with the chemistry of living organisms and of vital processes.
    • Hematology Laboratory: It is responsible for making hemoglobin determinations, coagulation time studies, red and white cell counts and special blood pathology studies for anemia and leukemia, etc.
    • Para Cytology Laboratory: It studies the presence of parasites, the cysts and ova's of the parasites that are found in the feces.
    • Serology Laboratory: It does blood agglutination tests, Wassermann tests, VD.
    • Blood Bank: It has the responsibility of collecting and processing all blood used in the hospital for transfusions. It makes studies of new born infants, who may have hemolytic diseases, and does antibody studies on the prenatal patients.
    • Histopathology Laboratory: It prepares tissues for gross and microscopic studies.
      Small hospitals, which do not have a pathology department, send specimens to be investigated to a central pathology service or to a large hospital.
  2. Pharmacy Department
    The pharmacy department has the responsibility for selecting, compounding, storing and dispensing all drugs and medications for inpatients and outpatients. The pharmacy should be under the supervision of registered pharmacists.
  3. Physical Medicine and Rehabilitation Department
    The department treats patients, who have functional disabilities resulting from disease conditions or injuries. It has several specialities such as, physical therapy, occupational therapy, speech therapy and vocational training. This department is under the direction of a well qualified physician, who has special training in the field of physical medicine and rehabilitation. The staff should include therapists with qualification in the various specialities. The work of this department is one part of the total patient care plan.
  4. Radiology Department
    This department functions under the control of radiologist and qualified technical staff. It has the following diagnostic and therapeutic services for inpatients and outpatients, such as,
    • Radiographic examinations and their interactions.
    • X-ray, radium, radio active cobalt and other radioactive therapies.
    • Radioactive isotopes tracer.
    • Radioactive isotopes therapy.
  5. Dietary Department (Catering)
    In most hospitals, this department is under the direction of a trained dietician. The department is charged with:
    • Ordering and preparation of food
    • Tray service
    • Diet teaching.
The dietician is a member of the health team and works closely with nursing service personnel in meeting the patient's nutritional needs and in teaching. He/she is responsible for the ordering of supplies and the supervision of all staff engaged in the preparation and delivery of food.
The kitchen should have ample light and air and should be as close as possible to the stairs, the dining rooms and the elevators. Procedures for handling dishes for communicable disease patients should be separated from general patients.
A periodic complete physical examination including X-ray of chest, analysis of stool and urine should be considered in order to detect silent carriers and take appropriate action. Daily inspection of personal appearance and hygiene also are important.
Three Types of Dietary Services are in use:
  • Centralized services
  • Decentralized services
  • A combination of both.
Outpatient Department
This is a combination of several departments. It is a miniature of the hospital except that the patients are ambulatory. Services are provided by specialists. Individuals may attend this department for the purpose of receiving treatment, or to enable a physician to asses their progress following discharge from hospital.
Accident and Emergency Department (A and E)
In most large hospitals, people who are classified as “emergency admissions”, are received into this department to receive life-saving services immediately needed after thorough examination by the responsible physician, i.e. road accidents, people who become suddenly very ill, etc. Arrangements for admission to hospital are made if necessary.
Some accidents and emergency departments have their own operating rooms, where minor surgeries can be performed, a plaster room, where casts are applied, and other services, such as X-ray and pharmacy.30
Operating Theater
Depending on the size of the hospital, there may be one or more number of operating rooms. In addition to the rooms, where surgeries are performed, there are sterilizing rooms, anesthesia rooms, recovery rooms, utility and storage rooms, staff amenities such as offices, toilets, etc.
In addition to these departments mentioned, large hospitals may provide other services such as intensive care, education department, blood bank, referral services to other hospitals, etc.
Admitting Department
This department has the responsibility for admitting the patient to the hospital. It should maintain good public relations. The patient, family and friends must be treated with utmost respect, courtesy and tact. Appropriate answers are to be given upon enquiries about the hospital.
Personnel Department (Functions)
  • Recruitment of personnel.
  • Interviewing.
  • Promotion and transfer.
  • Termination of employment.
  • In-service training.
  • Safety.
  • Health programs.
  • Recreation.
  • Remuneration and incentives.
Purchasing Department
This department has the responsibility for purchasing all supplies and equipment for the hospital.
Medical Records
This is one of the important departments in the hospital. The patient's records (charts, X-rays, etc.) are valuable not only to the patient but also to the doctor and to medical and nursing education and research.
This department has the responsibility for collecting the money, which is owed to the hospital, paying for supplies and equipment, handling all records pertaining to hospital finance, assisting with budget, etc.
Housekeeping Department (Domestic Services)
This department's main function is to keep the hospital clean. It plays an important role in hospital hygiene and infection control.
Laundry Department
The laundry takes care of the entire linen of the hospital. It has the responsibility of washing, repairing and replacing linen (if it is on contract basis). The location should be as far as possible from patient services areas to reduce noise. Linen which requires special care should be marked, e.g. infectious or from isolation, etc. Nursing personnel should be careful and alert the laundry workers to the dangers of needles or sharp instruments sent unintentionally.
Centralization of laundry services promotes efficient and quick service.31
Mechanical Department
Electricity, water supply, heat, air conditioning, etc. are looked after by the mechanical department.
Maintenance Department
The maintenance department keeps the hospital in good condition. Carpenters, painters, gardeners, etc. are included in the personnel of this department.
Central Sterile Supply Department (CSSD)
In modern hospitals, the trend is toward centralization of preparation and sterilization of supplies and equipments. The location should be as central as possible within the hospital with ample light. Where space conditions permit, this department should adjoin the operating department, since it uses a large amount of surgical supplies.
Purpose of CSSD
  1. To prepare and furnish other departments and nursing units with sterile equipment and supplies needed in patient care.
  2. To ensure:
    • Standardization, and better utilization and control of supplies and equipments used for diagnosis and treatment.
    • More adequate methods of sterilization than on a nursing unit.
    • Early detection of mechanical defects in equipments through regular checks.
    • Economy of time and better care.
Modern hospitals use elevator between the CSSD and nursing units. Items not used within 7-10 days should be re-sterilized, as per the infection control policy.
Social Service Departments
This department assists in obtaining financial aid for patients and their families. It advises on the agencies through which, help of various kinds can be arranged. It serves as a liaison between the patient and community agencies.
The department consists of two main classifications:
  1. Professional nursing personnel: They are the director, matrons assistants, supervisors, senior nurses, and staff nurses.
  2. Nonprofessional nursing service personnel: They are aids, orderlies and clerks.
Functions of the Nursing Service Department
  1. To plan, provide and evaluate nursing care for patient and families.
  2. To define and implement the philosophy, objectives and standards for nursing care of patients.
  3. To provide and implement a departmental plan of administrative authority, which delineates responsibilities and duties of each category of nursing personnel.
  4. To coordinate the functions of the department with the functions of all other departments.
  5. To estimate the requirements of the department.
  6. To interpret hospital and nursing service objectives to the patient and community.
  7. To participate in the formulation of personnel policies, to implement established policies and evaluate their effectiveness.
  8. To develop an effective system of nursing records and reports.
  9. To estimate needs for facilities, supplies and equipment.
  10. To participate in financial planning.
  11. To participate in studies and research projects for the improvement of patient care and hospital services.
  12. To provide and implement continuing education programs for all nursing personnel.
  13. To participate or facilitate all educational programs of students in the health care field.
The nursing unit is referred to as the inpatient care unit, or the hospital unit or ward.
  1. The nursing unit is the place, where patients actually live during their stay in the hospital.
  2. The nursing unit is a section of a general hospital that includes a nursing station, the beds it serves an associated facilities needed to carry out nursing care.
Functions of the Nursing Unit
  1. Provide and maintain the highest quality patient care with the lowest possible cost.
  2. Furnish the most desirable environment (safe, comfortable and pleasant) for patients and health service personnel, i.e. medical and nursing staff as well as other hospital personnel.
  3. Consider needs of patients’ families and significant others.
  4. Provide adequate space to facilitate the carrying out of all the activities needed, i.e. using different types of equipment with minimum waste of personnel time.
  5. Promote job satisfaction of the health service personnel.
Types of Nursing Unit
  1. General units: Where there are similar medical or surgical treatments, e.g. medical or surgical units.
  2. Special units: Where there are similar—
    1. Patient's age, e.g. pediatrics, geriatrics, etc.
    2. Patient's needs, e.g. recovery room, nursery, intensive care unit, etc.
    3. Medical speciality, e.g. neurology, gynecology, dermatology, ophthalmology, etc.
    4. Patient behavior, e.g. psychiatry.
Recently, a system known as Progressive Patient Care (5 PPC) has been adopted in some hospitals– Intensive Care Unit (ICU), Intermediate Care Unit, Self-care Unit, Long-term Care Unit and Home Care Unit. This system is one of organizing the hospital units, around the medical needs of patients and grouping them according to their degree of illness and their needs of nursing care.
Though it is advantageous in terms of economy of manpower and material, it has failed to sustain practicality, due to the current trends in specialization and super specialization.