The Evolution of Practical Nursing

NURS 195 PN Leader and Manager Capstone

Chapter 7 1836 to the Present
Historical Perspective -Diversity
1836 - First school of nursing Germany
1873 - Americas first professionally trained nurse
Linda Richards.






1879 First African-American graduate nurse
Mary Mahoney



1888 First American Indian Nurse Elizabeth
Weston

Practical Nursing Milestones
1892-1893 YWCA Ballard School for Practical
Nursing opened Brooklyn, NY
The focus for practical nursing began with home
care, specifically children and the chronically ill.

Titles bestowed on early practical nurses varied:
From attendant to trained nurse,
To self-proclaimed nurse to midwife
And finally practical nurse

Practical nurses were first licensed in the State of
Mississippi in 1914.





1914 1918 World War I :
Shortage of practical nurses
Army School of Nursing established

1939 1945 World War II:
Shortage of RNs creates need for more practical
nurses.

1941 National Association of Practical Nurse
Education and Service (NAPNES) founded
www.NAPNES.org.

1949
NFLPN (National Federation of Licensed Practical
Nurses), professional organization founded.
http://www.NFLPN.org

The title Licensed Practical Nurse - recommended

World War II had the greatest influence in the role
change of practical nursing in modern times from the
home to working in the hospitals due to the nursing
shortage.

1950 1953 Korean conflict Nurses serve officially
as part of the military.
1951 Journal of Practical Nursing (now Practical
Nursing Today) published.

1961 NLN accredits practical nursing programs.
1961 1973 Vietnam War military nursing
continues to expand, in addition to MASH units, flight
nurses and hospital ships.



1979 NLN publishes 1
st
list competencies for
practical nursing programs.

1994 First NCLEX-PN

1996 Certification exams available for LPNs for
long-term care.

2007 Increase demand for LPNs in nursing homes
and extended care facilities.
Famous Nurse Pioneers
Florence Nightingale was:
Influential in transitioning nursing to the modern age.
The first to emphasize the environment as influencing the
course of illness, accepted as first nursing theorist.
Established a school for nurse training.
Insisted nurses meet a standard by being of good character.
Authored several books on nursing.

Mary Seacole a nurse from Jamaica funded a
hospital during the Crimean war 1853-1865
(currently back in the news), and assisted Florence
Nightingale in caring for wounded soldiers.

1861-1865 - Dorothea Lynde Dix first a teacher and
started nursing at age 39 years. Organized nurses
to care for the North, Union troops Civil War.
Later served as patient advocate for the mentally ill
and for prisoners.

1864 - Clara Barton established the first chapter
of the American Red Cross.

1893 Lillian Wald, a trained nurse who established
the Henry Street Settlement that, provided the poor
with healthcare, and social, educational and
recreational services.
Modern Roles of the Practical Nurse
Charge nurse in nursing homes;
staff nurse in clinics, rehab, and home-health care
Private duty
Military service

If allowed by a States Nurse Practice Act, a
competent LPN can perform complex nursing skills
not taught in their basic educational program if
delegated by the RN.
The RN must teach the skill.
The RN must observe a return demonstration.
The RN must document the teaching / learning process
in the LPNs employee file.
The RN must provide ongoing supervision.

American Nurses Association
(ANA)
Membership in a professional nursing organizations
helps nurses keep up to date with the needs and
current practice of their profession.
ANA Mission Statement: Nurses advancing our
profession to improve health for all.
The American Nurses Association advances the
nursing profession by:
fostering high standards of nursing practice,
Promoting the rights of nurses in the workplace,
Projecting a positive and realistic view of nursing,
And by lobbying the Congress and regulatory agencies
on health care issues affecting nurses and the public.
http://www.nursingworld.org

NURS 195 Chap 10:Theory,
Research, and Evidence-Based
Practice
Rationale for Nursing Theory
Nursing theory is nursing knowledge, which lays
the foundation for nursing curriculum.

The concepts important to
nursing are:


person (recipient of care),
health (the goal of nursing),
and environment (the setting where nursing care
takes place).
Nursing Theorists
First Nursing Theorist Florence Nightingale
She believed that the environment had a direct
relationship with illness and a patients chance for
recovery.

She was the first to emphasize the importance of:
Good ventilation
Warmth
Decreased noise
Amount of light
And Cleanliness

Abraham Maslows Human Needs
Theory
States the needs common to all people are
physical, external, internal and psychological.
Needs are set up in a hierarchy.
Unmet needs create tension, and the person
reacts to meet the need.
When needs are met, not as strong a focus or
motivator.
Needs that dominate can vary throughout life.

Application of Maslows Theory
The LPN is caring for a new postoperative
mastectomy patient and has several tasks that
need to be completed for this patient. The tasks
include teaching the patient about wound care,
serving the patients breakfast tray, and
discussing the change in body image due to the
surgical scar and loss of her breast. How can the
nurse use Maslows Hierarchy of needs to
prioritize these tasks?
Self-
Actualization
Self-esteem
Love &
Belonging
Safety & Security
Physiologic
Answer
According to Maslow, the LPN should prioritize
the physical needs first (serving the breakfast
tray), the safety needs second (wound care), and
finally the esteem needs (discussing the change
in body image).
Why: because Maslows theory suggests that the
most basic level of needs must be met before the
individual will strongly desire the higher-level
needs.
The most basic level is physical needs,
Then safety needs,
Love and belonging needs,
Esteem needs.
Then self-actualization.
Dorothea Orems Self-Care Deficit
Theory
Consists of three sub-theories:
Self-care
Self-care deficit
Nursing system
Patient application:
Developmental needs
Physiologic needs
Psychosocial needs
Application of Orems Self-care
Deficit Theory
As an LPN you are working at a podiatrists office.
Your first patient of the day said he has noted
persistent pain in his right foot for the past 2 days.
The patient states the pain is worse when he
walking. The patient states he has diabetic
neuropathy. You ask the patient to remove his
shoes and socks and you immediately notice
blood on the sock and a pin stuck in his foot.
After the podiatrist provides the patient with the
needed medical care and pain relief. How will
you use Orems Self-care deficit theory to help
your patient?
Answer
Using the Nursing Process:
You collect data
Patient complaining of persistent new pain (past two days).
Patient has diabetic neuropathy which you know causes
pain, but also inhibits feeling in feet related to trauma.
Patient unaware of pin in foot despite persistent pain and blood
on sock.
Identification of self care deficit-
Patient does not respond to internal or external cues and was
slow to respond to self-care needs.
Nursing System-
Empower Patient supportive role
Intervention - education
Examine feet daily, use a mirror or ask for family assistance
Never go barefoot, wear soled slippers to the bathroom
Take note of new or worsening pain and seek medical
attention.
Madeline Leiningers Culture Care
Theory
Identifies two kinds of care in every culture:
Generic (home remedies)
Professional (provided by people who are trained to
provide care)
Three Cultural care modes to guide nursing
decisions:
care preservation / maintenance
Accomodation or negotiation
Repatterning or restructuring
(Hill & Howlett, p. 112 - provides 3 good examples
this theories use in practice).

Rosenstocks Health Belief
Theory
Explanations for why patients choose to or not to
act on a treatment, prevention in healthcare.

This theory helps us understand:
that perceptions vary and may have no basis in
reality
that some beliefs are connected to existing barriers
a cue perceived by the patient is what motivates
them to action.
This theory can be used with the nursing process
(collecting data, planning, implementing, evaluating)
:

This is accomplished by asking questions
What are their perceptions of health care?
How do their beliefs affect their health care choices?
What is important to them?

By getting to know the patient, use that specific
information to:
Promote health
Develop individualized interventions and outcomes
Callista Roys Adaptation Model
The patient is seen as a holistic adaptive system.
Both internal and external stimuli affect this
system.
Focal something direct (ie, pain)
Contextual factors that affect the focal stimuli (ie,
bright lights or noise affecting migraine pain)
Residual both internal & external factors such as
a memory of previous pain and its previous effect
(ie, receiving an injection as a child)
Coping methods:

Regulator subsystem (internal response to stimuli)
Neural
chemical
endocrine

Cognator subsystem (coping mechanisms used to
respond to stimuli)
Learning
Processing
Judging
emotion

Adaptive modes:

Physiologic (ie, senses, fluids, electrolytes, neurologic,
and endocrine systems)
Self-concepts (the patients psychological and spiritual
aspects)
role functions (the patients role in society)
Interdependence (the patients support system r/t love,
respect, values)

Response:

Adaptation (the patient reaches goal of recovery)
Ineffective (patient does not survive / poor outcome)


Jean Watsons Theory of Human
Care
Health = harmony between the body, mind, and
spirit.
Illness = lack of harmony within the self.
Nurse role = a caring process to help the patient
regain harmony & health.
Patient outcome = problem solved, increased
self-knowledge & self-healing
Results = nurse and patient
both grow through the caring
process
Application of Watsons Theory of
Human Care
You are working as an LPN at a local hospital. You
are caring for a 42 year old woman admitted with
pneumonia and diabetes Type II. She states that she
just does not understand why her blood sugar is
higher than usual while she is in the hospital since
she is not consuming any more food than usual. As
her nurse you respond saying:
A) That since she has high blood sugar, she must be
sneaking food from visitors, because there is no good
reason why her blood glucose should not be controlled
in the hospital.
B) Acknowledge patients concern and explain that there
are many things like stress, inactivity and infection that
can increase blood glucose while she is in the hospital,
then report patient concern to assigned RN.
C) That you really dont know why.

Answer
The answer is B:
Rationale:
Patients are generally more sedentary while they
are sick.
In addition the bodys physical response to infection
and emotional stress can increase the blood
glucose.
Also using sensitivity when responding nurtures a
helping and trusting relationship with the patient.
This assists in collaborative problem solving, which
supports the goal of recovery and self-care,
Watsons Theory of Caring.
Hildegard Peplaus Interpersonal
Relations Theory
A system for developing a therapeutic relationship as part
of treatment.
Four phases:
Orientation patient seeks assistance for a need, nurse helps
patient recognize the problem
Identification the nurse provides help, patient responds with
understanding.
Exploitation the patient has a dependent relationship with
the nurse, and uses the help to explore options.
Resolution the dependent behavior ends and the therapeutic
relationship also comes to an end. The goal is for the patient
be independent for self.
Nurse role:
resource person and teacher,
leader and surrogate
counselor
What is Research?
The systematic process of analyzing data and
sources in order to establish facts and reach new
conclusions / new knowledge.
Research in any profession supports existing
knowledge and develops new knowledge based on
observation and experimentation
Nursing research adds new knowledge to improve
nursing practice.
Identifies nursing interventions effectiveness
Provides evidence support quality & cost-
effectiveness of nursing services
Generates further knowledge for nursing education,
clinical practice, to keep delivery of nursing services
current.
Types of Research
Quantitative research (Objective study)
Usually has two variables (events the researcher is
attempting to measure).
One variable receives the intervention
The other variable does not (ie, receives standard
of care, placebo)
Numeric data is collected & measured using statistics
which:
Describe the variable results
Examine relationships among the variables
Determine cause and effect between variables



Qualitative research is subjective.
Data is often collected using interviews.
There are six common designs (2 mentioned below):
Phenomenological studies lived experiences or how the
subject perceives the experience.
Goal is to search for meaning, themes and patterns.
Grounded theory is a study in which the subjective data is
collected and then a theory is developed that is grounded in the
data.
Used to manage health problems
Purposeful sampling is followed, by looking for diverse
subjects with the thought that differences may shed new light
on the same phenomena goal


Pause for Practice
Lets play name that research article!
Qualitative or Quantitative?
Can you find the Abstract (summary of the
research)?
What were the results of the research?

discussion
collaboration
Background of the Evidence Based
Practice Movement
Dr. Cochrane epidemiologist (1901-1988)
Supported the scientific process in healthcare and
advocated for Randomized Controlled Trials.
Cochrane Collaboration - organization (1993)
promoted the accessibility of research findings related to
evidence-based healthcare interventions.
Institute of Medicine organization (1999)
published reports on errors in healthcare and need for
reform
(2001) published that patients should receive care
supported by scientific evidence.
Insurance companies pay for or deny payment based
on healthcare that is evidence-based or not.
Patients / families seek the latest and most effective
treatment


The Triangle of Evidence-based
Practice
Best
Practices
Nurses
Clinical
Expertise
Quality
Patient
Care
Patient
Preferences
Determination of Evidence-Based
Practice Use
Best evidence is determined using a systematic
process:
The clinical question is investigated objectively.
The existing literature / resources are searched for
the latest, most relevant research evidence
pertaining to the clinical question.
Expert(s) systematically review a summary of
results from selected studies.
Guidelines are determined, which are specific
practice recommendations derived from these
research articles.

Elements of Evidence-Based
Practice and the Nursing Role
Current quality patient care is provided when the
nurse:
Uses best research evidence
Develops and maintains clinical expertise
Considers and incorporates patient preferences in
nursing care
AND
The practical nurse role is to question the basis
for nursing actions by checking it with:
Current professional nursing articles / sources
Question is there evidence to support the practice?



Application of the Evidence in
Practice
You are a LPN working in a busy rehab unit at a
local hospital. You are assigned to provide
colostomy care to a patient. Before proceeding
you search the web for information on colostomy
care. Is this the correct source of information to
utilize for this procedure?
Why or Why
Not?
Answer
No. All nurses need to check and follow protocols
and procedures for nursing interventions of the
agency in which they practice.
Protocols are the general outlines used to manage
a clinical situation (ie, care plan).
Procedures include the detailed steps of nursing
interventions for implementing the protocol.
Practical nurses can participate in research and
evidence based practice by reviewing current
articles in professional sources .
Evidence Based-practice Resources
Cumulative Index of Nursing and Allied Health
Literature (CINAHL)
A source for practical nurses for evidence based-
practice interventions.
http://www.ebscohost.com/nursing
Questions