![5
CHAPTER 1 Professional Nursing
direct patient care. The LPN/LVN is a nurse who completes
a practical nursing program and passes a licensure examina-
tion (NCLEX-PN®). The LPN/LVN practices under the
supervision of an RN or other licensed person. The respon-
sibilities and scope of practice are set by each state board of
nursing. An LPN/LVN, or in Canada an RN assistant (RNA),
generally receives 1 year of education and clinical preparation
in a community college or other agency. Some RN programs
allow an LPN to enter the program at an advanced level.
Registered Nurse Education
As a profession nursing requires that its members possess a
significant amount of education. There are various educa-
tional routes for becoming a registered nurse (RN). Cur-
rently in the United States an individual becomes an RN by
earning an associate degree, diploma, or baccalaureate degree
program in nursing and by passing the NCLEX-RN® exami-
nation. The baccalaureate degree is required as the entry to
practice standard for RNs in all provinces of Canada except
Quebec (Canadian Nurses Association [CAN], 2016a).
Nursing education provides the solid foundation for practice,
and it responds to changes in health care created by scientific
and technological advances.
Advanced Education
Some roles for RNs require advanced graduate degrees. A
graduate degree provides the advanced clinician with strong
skills in nursing science and theory, with an emphasis on the
basic sciences and research-based clinical practice related to
a specialty. A master’s degree in nursing (e.g., Master of Arts
in Nursing [MA], Master of Nursing [MN], or Master of
Science in Nursing [MSN]) is for RNs seeking roles such as
nurse educator, nurse administrator, clinical nurse leader,
nursing informatics specialist, or advanced practice registered
nurse (APRN). Some programs require the RN to have a
Bachelor of Science in Nursing (BSN) degree before entry;
other programs offer entrance to associate degree–prepared
nurses who take bachelor’s level courses as they progress
through the curriculum toward the master’s degree.
Some roles within nursing require doctoral degrees. There
are two doctorate degree in nursing options for nurses. The
Doctor of Philosophy (PhD) has a focus on research, and the
Doctor of Nursing Practice (DNP) has a focus on advanced
clinical practice. The health care industry needs nurses pre-
pared at the doctorate level with advanced academic and
clinical preparation to educate nursing students and partici-
pate as members of the interdisciplinary health care team to
provide evidence-based, competent, safe patient care (IOM,
2010). Nurses with doctorates advance the profession by pro-
moting evidence-based practice, developing practice guide-
lines, conducting and disseminating research, developing
and testing theory, educating future nurses, and influencing
public policy and health care planning.
Continuing and In-Service Education
Continuing education programs are one way to promote
and maintain current nursing skills, gain new knowledge
PROFESSIONALISM
Nursing is a profession. A person who acts professionally is
conscientious in actions, knowledgeable in the subject, and
responsible to self and others. This means that as a nurse you
administer patient-centered care in a safe, conscientious, and
knowledgeable manner. Professions possess the following
characteristics:
• An extended education of members and a basic liberal
education foundation
• A theoretical body of knowledge leading to defined
skills, abilities, and norms
• Provision of a specific service
• Autonomy in decision making and practice
• A code of ethics for practice
Nursing shares each of these characteristics, offering an
opportunityforthegrowthandenrichmentof allitsmembers.
Licensed Practical Nurse/Licensed
Vocational Nurse Education
A licensed practical nurse (LPN) or licensed vocational
nurse (LVN) is educated in basic nursing techniques and
PICO Question: Are patient outcomes improved in hos-
pitals with adequate nursing staffing versus hospitals
with lower nursing staffing?
SUMMARY OF EVIDENCE
There is a growing body of research that shows that nurse
staffing does impact patient outcomes, patient survival, and
the occurrence of adverse events. A secondary data analysis
from 661 hospitals showed that there was a significantly
lower 30-day readmission rate for patients with heart failure
in hospitals that had high nurse staffing, thus reducing health
care costs (Giuliano et al., 2016). Higher nurse staffing was
also found to significantly increase the survival of patients in
an intensive care unit (West et al., 2014). Patients experienc-
ing an in-hospital cardiac arrest were more likely to survive
when there was a decreased patient-to-nurse ratio (McHugh
et al., 2016). Cho et al. (2016) found that larger numbers of
patients assigned to a nurse increased the occurrence of
medication errors, pressure injury formation, and falls with
injuries. Studies demonstrating the positive impact that
nurse-to-patient ratios have on outcomes provide nursing
administrators with evidence to support hiring of qualified
professional nurses.
APPLICATION TO NURSING PRACTICE
• Consider the nurse-to-patient ratio when looking at a hos-
pital or unit for employment.
• Adequate nursing levels help to improve the nursing work
environment (Cho et al., 2016).
• Improved working conditions increase the likelihood of
patient survival in emergency events (McHugh et al.,
2016).
• Continuing research needs to be conducted to study the
economic impact of nurse staffing and improved patient
outcomes (Giuliano et al., 2016).
BOX 1.1 EVIDENCE-BASED PRACTICE](https://image.slidesharecdn.com/32772-250402155523-f2319dc6/85/Essentials-for-nursing-practice-Ninth-Edition-Hall-27-320.jpg)
![17
CHAPTER 2 Health and Wellness
(Fig. 2.3). According to Maslow, individuals have to meet
lower level needs before they are able to satisfy higher level
needs. As people meet the needs of one level, they move up
to the next level. Unmet needs motivate human behavior.
A person needs to meet basic physiological needs such as
oxygen, water, food, sleep, and shelter before progressing to
higher level needs. When basic needs are not met, an affected
person feels sick or irritated or experiences pain or discom-
fort. These feelings motivate an individual to satisfy the need
(Maslow, 1970, 1987). The second level on the hierarchy of
needs consists of safety and security needs, which include
establishing stability and consistency. These psychological
needs include the security of a home and a family. For
example, a woman in an abusive relationship is unable to
move to the next level of love and belongingness because she
is constantly concerned for her safety. The third level on the
hierarchy, love and belongingness, is a desire to belong to
groups. It consists of the need to feel love by others and to be
accepted. The fourth level deals with the need for self-esteem.
Self-esteem results from mastery of a task and includes the
recognition gained from others. The highest level of needs on
the hierarchy is self-actualization, which is the desire to
become everything that one is capable of becoming. Indi-
viduals at this level are concerned with maximizing their
potential.
Maslow (1970) expanded his model to include cognitive,
aesthetic, and transcendence needs to incorporate needs
not merely the absence of disease. The model is a framework
that integrates the perspectives of nursing with behavioral
science and factors that influence health behaviors. You use it
with individuals, not communities.
Health promotion is behavior motivated by the desire to
increase well-being and actualize human health potential,
whereas health protection is behavior motivated by a desire
to avoid illness, detect it early, or maintain function within
the constraints of an illness (Pender et al., 2011). This model
describes the multidimensional nature of people as they
interact within their environment to pursue health (Pender
et al., 2011). The model focuses on three areas:
1. Individual characteristics and experiences
2. Behavior-specific cognitions and affect
3. Behavioral outcomes
It also organizes cues into a pattern to explain the likelihood
of a patient developing health promotion behaviors (Pender
et al., 2011). You can use this model to help your patients
carry out healthy behaviors in their daily lives.
Basic Human Needs Model
Maslow’s hierarchy of needs (Maslow, 1954) helps you
understand an individual’s motivation to achieve optimal
health. This model explains the basic needs of patients and
families, their behaviors, and their readiness to take part in
health activities. Maslow’s original model describes human
needs using a hierarchical pyramid divided into five levels
Individual perceptions Modifying factors Likelihood of action
Demographic variables
(e.g., age, sex, race,
ethnicity)
Sociopsychological
variables (e.g., personality,
social class, peer and
reference group pressure)
Mass media campaigns
Advice from others
Reminder postcard from physician or dentist
Illness of family member or friend
Newspaper or magazine article
Cues to action
Perceived susceptibility to
disease X
Perceived seriousness
(severity) of disease X
Perceived benefits of
preventive action
Perceived barriers to
preventive action
minus
Likelihood of taking
recommended
preventive health
action
Perceived threat of
disease X
FIG 2.1 Health belief model. (Data from Becker MH, Maiman LA: Sociobehavioral determinants
of compliance with health and medical care recommendations, Med Care 13[1]:10, 1975.)](https://image.slidesharecdn.com/32772-250402155523-f2319dc6/85/Essentials-for-nursing-practice-Ninth-Edition-Hall-39-320.jpg)
![§ 1
By the tacit admission of one of the ablest opponents of the theory of
foreign influence, Hellenic religion as fixed by Homer for the Hellenic
world was partly determined by Asiatic influences. Ottfried Müller decided
not only that Homer the man (in whose personality he believed) was
probably a Smyrnean, whether of Æolic or Ionic stock,19 but that Homer’s
religion must have represented a special selection from the manifold Greek
mythology, necessarily representing his local bias.20 Now, the Greek cults
at Smyrna, as in the other Æolic and Ionic cities of Asia Minor, would be
very likely to reflect in some degree the influence of the Karian or other
Asiatic cults around them.21 The early Attic conquerors of Miletos allowed
the worship of the Karian Sun-God there to be carried on by the old priests;
and the Attic settlers of Ephesos in the same way adopted the neighbouring
worship of the Lydian Goddess (who became the Artemis or “Great Diana”
of the Ephesians), and retained the ministry of the attendant priests and
eunuchs.22 Smyrna was apparently not like these a mixed community, but
one founded by Achaians from the Peloponnesos; but the genera] Ionic and
Æolic religious atmosphere, set up by common sacrifices,23 must have been
represented in an epic brought forth in that region. The Karian civilization
had at one time spread over a great part of the Ægean, including Delos and
Cyprus.24 Such a civilization must have affected that of the Greek
conquerors, who only on that basis became civilized traders.25
It is not necessary to ask how far exactly the influence may have gone in the
Iliad: the main point is that even at that stage of comparatively simple
Hellenism the Asiatic environment, Karian or Phoenician, counted for
something, whether in cosmogony or in furthering the process of God-
grouping, or in conveying the cult of Cyprian Aphrodite,26 or haply in
lending some characteristics to Zeus and Apollo and Athênê,27 an influence](https://image.slidesharecdn.com/32772-250402155523-f2319dc6/85/Essentials-for-nursing-practice-Ninth-Edition-Hall-59-320.jpg)
![in the adaptations of myth for liturgical purposes by Stesichoros (fl. circa
600 B.C.) we appear to have the first open trace of a critical revolt in the
Greek world against immoral or undignified myths.50 In his work, it is fair
to say, we see “the beginning of rationalism”: “the decisive step is taken:
once the understanding criticizes the sanctified tradition, it raises itself to be
the judge thereof; no longer the common tradition but the individual
conviction is the ground of religious belief.”51 Religious, indeed, the
process still substantially is. It is to preserve the credit of Helena as a
Goddess that Stesichoros repudiates the Homeric account of her,52
somewhat in the spirit in which the framers of the Hesiodic theogony
manipulated the myths without rejecting them, or the Hebrew redactors
tampered with their text. But in Stesichoros there is a new tendency to
reject the myth altogether;53 so that at this stage freethought is still part of a
process in which religious feeling, pressed by an advancing ethical
consciousness, instinctively clears its standing ground.
It is in Pindar, however (518–442 B.C.), that we first find such a mental
process plainly avowed by a believer. In his first Olympic Ode he expressly
declares the need for bringing afterthought to bear on poetic lore, that so
men may speak nought unfitting of the Gods; and he protests that he will
never tell the tale of the blessed ones banqueting on human flesh.54 In the
ninth Ode he again protests that his lips must not speak blasphemously of
such a thing as strife among the immortals.55 Here the critical motive is
ethical, though, while repudiating one kind of scandal about the Gods,
Pindar placidly accepts others no less startling to the modern sense. His
critical revolt, in fact, is far from thoroughgoing, and suggests rather a
religious man’s partial response to pressure from others than any
independent process of reflection.56
“He [Pindar] was honestly attached to the national religion and to its varieties in old local
cults. He lived a somewhat sacerdotal life, labouring in honour of the Gods, and seeking to
spread a reverence for old traditional beliefs. He, moreover, shows an acquaintance with
Orphic rites and Pythagorean mysteries, which led him to preach the doctrine of
immortality, and of rewards and punishments in the life hereafter. [Note.—The most
explicit fragment (θρῆνοι, 3), is, however, not considered genuine by recent critics.]... He is
indeed more affected by the advance of freethinking than he imagines; he borrows from the](https://image.slidesharecdn.com/32772-250402155523-f2319dc6/85/Essentials-for-nursing-practice-Ninth-Edition-Hall-63-320.jpg)
![neologians the habit of rationalizing myths, and explaining away immoral acts and motives
in the Gods; but these things are isolated attempts with him, and have no deep effect upon
his general thinking” (Mahaffy, Hist. of Greek Lit. i, 213–14).
For such a development we are not, of course, forced to assume a foreign
influence: mere progress in refinement and in mental activity could bring it
about; yet none the less it is probable that foreign influence did quicken the
process. It is true that from the beginnings of the literary period Greek
thought played with a certain freedom on myth, partly perhaps because the
traditions visibly came from various races, and there was no strong
priesthood to ossify them. After Homer and Hesiod, men looked back to
those poets as shaping theology to their own minds.57 But all custom is
conservative, and Pindar’s mind had that general cast. On the other hand,
external influence was forthcoming. The period of Pindar and Æschylus
[525–455 B.C.] follows on one in which Greek thought, stimulated on all
sides, had taken the first great stride in its advance beyond all antiquity.
Egypt had been fully thrown open to the Greeks in the reign of
Psammetichos58 (650 B.C.); and a great historian, who contends that the
“sheer inherent and expansive force” of “the” Greek intellect, “aided but by
no means either impressed or provoked from without,” was the true cause,
yet concedes that intercourse with Egypt “enlarged the range of their
thoughts and observations, while it also imparted to them that vein of
mysticism which overgrew the primitive simplicity of the Homeric
religion,” and that from Asia Minor in turn they had derived “musical
instruments and new laws of rhythm and melody,” as well as “violent and
maddening religious rites.”59 And others making similar à priori claims for
the Greek intelligence are forced likewise to admit that the mental transition
between Homer and Herodotos cannot be explained save in terms of “the
influence of other creeds, and the necessary operation of altered
circumstances and relations.”60 In the Persae of Æschylus we even catch a
glimpse of direct contact with foreign skepticism;61 and again in the
Agamemnon there is a reference to some impious one who denied that the
Gods deigned to have care of mortals.62 It seems unwarrantable to read as
“ridicule of popular polytheism” the passage in the same tragedy:63 “Zeus,
whosoever he be; if this name be well-pleasing to himself in invocation, by](https://image.slidesharecdn.com/32772-250402155523-f2319dc6/85/Essentials-for-nursing-practice-Ninth-Edition-Hall-64-320.jpg)
![this do I name him.” It may more fitly be read64 as an echo of the saying of
Herakleitos that “the Wise [= the Logos?] is unwilling and willing to be
called by the name of Zeus.”65 But in the poet’s thought, as revealed in the
Prometheus, and in the Agamemnon on the theme of the sacrifice of
Iphigeneia, there has occurred an ethical judgment of the older creeds, an
approach to pantheism, a rejection of anthropomorphism, and a growth of
pessimism that tells of their final insufficiency.
The leaning to pantheism is established by the discovery that the disputed lines, “Zeus is
sky, earth, and heaven: Zeus is all things, yea, greater than all things” (Frag. 443), belonged
to the lost tragedy of the Heliades (Haigh, Tragic Drama of the Greeks, 1896, p. 88). For
the pessimism see the Prometheus, 247–51. The anti-anthropomorphism is further to be
made out from the lines ascribed to Æschylus by Justin Martyr (De Monarchia, c. 2) and
Clemens Alexandrinus (Stromata, v, 14). They are expressly pantheistic; but their
genuineness is doubtful. The story that Æschylus was nearly killed by a theatre audience
on the score that he had divulged part of the mysteries in a tragedy (Haigh, The Attic
Theatre, 1889, p. 316; Tragic Drama, pp. 49–50) does not seem to have suggested to
Aristotle, who tells it (Nicomachean Ethics, iii, 2), any heterodox intention on the
tragedian’s part; but it is hard to see an orthodox believer in the author either of the
Prometheus, wherein Zeus is posed as brutal might crucifying innocence and beneficence,
or of the Agamemnon, where the father, perplexed in the extreme, can but fall back
helplessly on formulas about the all-sufficiency of Zeus when called upon to sacrifice his
daughter. Cp. Haigh, Tragic Drama, p. 86 sq. “Some critics,” says Mr. Haigh (p. 88), “have
been led to imagine that there is in Æschylus a double Zeus—the ordinary God of the
polytheistic religion and the one omnipotent deity in whom he really believed. They
suppose that he had no genuine faith in the credibility of the popular legends, but merely
used them as a setting for his tragedies; and that his own convictions were of a more
philosophical type,” as seen in the pantheistic lines concerning Zeus. To this Mr. Haigh
replies that it is “most improbable that there was any clear distinction in the mind of
Æschylus” between the two conceptions of Zeus; going on, however, to admit that “much,
no doubt, he regarded as uncertain, much as false. Even the name ‘Zeus’ was to him a mere
convention.” Mr. Haigh in this discussion does not attempt to deal with the problem of the
Prometheus.
The hesitations of the critics on this head are noteworthy. Karl Ottfried Müller, who is least
himself in dealing with fundamental issues of creed, evades the problem (Lit. of Anc.
Greece, 1847, p. 329) with the bald suggestion that “Æschylus, in his own mind, must have
felt how this severity [of Zeus], a necessary accompaniment of the transition from the
Titanic period to the government of the Gods of Olympus, was to be reconciled with the
mild wisdom which he makes an attribute of Zeus in the subsequent ages of the world.
Consequently, the deviation from right ... would all lie on the side of Prometheus.” This](https://image.slidesharecdn.com/32772-250402155523-f2319dc6/85/Essentials-for-nursing-practice-Ninth-Edition-Hall-65-320.jpg)
![There is reason to think that these early “schools” of thought were really
constituted by men in some way banded together,93 thus supporting each
other against the conservatism of religious ignorance. The physicians were
so organized; the disciples of Pythagoras followed the same course; and in
later Greece we shall find the different philosophic sects formed into
societies or corporations. The first model was probably that of the priestly
corporation; and in a world in which many cults were chronically
disendowed it may well have been that the leisured old priesthoods,
philosophizing as we have seen those of India and Egypt and Mesopotamia
doing, played a primary part in initiating the work of rational secular
thought.
The recent work of Mr. F. M. Cornford, From Philosophy to Religion (1912), puts forth an
interesting and ingenious theory to the effect that early Greek philosophy is a reduction to
abstract terms of the practice of totemistic tribes. On this view, when the Gods are figured
in Homer as subject to Moira (Destiny), there has taken place an impersonation of Nomos,
or Law; and just as the divine cosmos or polity is a reflection of the earthly, so the
established conception of the absolute compulsoriness of tribal law is translated into one of
a Fate which overrules the Gods (p. 40 sq.). So, when Anaximandros posits the doctrine of
four elements [he did not use the word, by the way; that comes later; see Burnet, ch. i, p.
56, citing Diels], “we observe that this type of cosmic structure corresponds to that of a
totemic tribe containing four clans” (p. 62). On the other hand, the totemistic stage had
long before been broken down. The “notion of the group-soul” had given rise to the notion
of God (p. 90); and the primitive “magical group” had dissolved into a system of families
(p. 93), with individual souls. On this prior accumulation of religious material early
philosophy works (p. 138).
It does not appear why, thus recognizing that totemism was at least a long way behind in
Thales’s day, Mr. Cornford should trace the Ionian four elements straight back to the
problematic four clans of the totemistic tribe. Dr. Frazer gives him no data whatever for
Aryan totemism; and the Ionian cities, like those of Mesopotamia and Egypt, belong to the
age of commerce and of monarchies. It would seem more plausible, on Mr. Cornford’s own
premises, to trace the rival theories of the four elements to religious philosophies set up by
the priests of four Gods of water, earth, air, and fire. If the early philosophers “had nothing
but theology behind them” (p. 138), why not infer theologies for the old-established deities
of Mesopotamia? Mr. Cornford adds to the traditional factors that of “the temperaments of
the individual philosophers, which made one or other of those schemes the more congenial
to them.” Following Dr. F. H. Bradley, he pronounces that “almost all philosophic
arguments are invented afterwards, to recommend, or defend from attack, conclusions
which the philosopher was from the outset bent on believing before he could think of any](https://image.slidesharecdn.com/32772-250402155523-f2319dc6/85/Essentials-for-nursing-practice-Ninth-Edition-Hall-73-320.jpg)
![the only realities are mental,131 a formula which eluded at once the
problems of Nature and the crudities of religion, and so made its fortune
with the idle educated class. Meant to support the cause of reason, it was
soon turned, as every slackly-held doctrine must be, to a different account.
In the hands of Plato it developed into the doctrine of ideas, which in the
later Christian world was to play so large a part, as “Realism,” in checking
scientific thought; and in Greece it fatally fostered the indolent evasion of
research in physics.132 Ultimately this made for supernaturalism, which had
never been discarded by the main body even of rationalizing thinkers.133
Thus the geographer and historian Hekataios of Miletos (fl. 500 B.C.),
living at the great centre of rationalism, while rejecting the mass of Greek
fables as “ridiculous,” and proceeding in a fashion long popular to translate
them into historical facts, yet affected, in the poetic Greek fashion, to be of
divine descent.134 At the same time he held by such fables as that of the
floating island in the Nile and that of the supernormal Hyperboreans. This
blending of old and new habits of mind is indeed perhaps the strongest
ground for affirming the genuineness of his fragments, which has been
disputed.135 But from his time forward there are many signs of a broad
movement of criticism, doubt, inquiry, and reconstruction, involving an
extensive discussion of historical as well as religious tradition.136 There had
begun, in short, for the rapidly-developing Greeks, a “discovery of man”
such as is ascribed in later times to the age of the Italian Renaissance. In the
next generation came the father of humanists, Herodotos, who implicitly
carries the process of discrimination still further than did Hekataios; while
Sophocles [496–405 B.C.], without ever challenging popular faith, whether
implicitly as did Æschylus, or explicitly as did Euripides, “brought down
the drama from the skies to the earth; and the drama still follows the course
which Sophocles first marked out for it. It was on the Gods, the struggles of
the Gods, and on destiny that Æschylus dwelt; it is with man that Sophocles
is concerned.”137
Still, there was only to be a partial enlightenment of the race, such as we
have seen occurring, perhaps about the same period, in India. Sophocles,
even while dramatizing the cruel consequences of Greek religion, never
made any sign of being delivered from the ordinary Greek conceptions of](https://image.slidesharecdn.com/32772-250402155523-f2319dc6/85/Essentials-for-nursing-practice-Ninth-Edition-Hall-80-320.jpg)
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- 7. i B R I E F C O N T E N T S UNIT 1 CONCEPTS IN NURSING 1. Professional Nursing, 1 Patricia A. Stockert 2. Health and Wellness, 15 Amy M. Hall 3. The Health Care Delivery System, 29 Patricia A. Potter 4. Community-Based Nursing Practice, 48 Edith Claros 5. Legal Principles in Nursing, 59 Lori Catalano 6. Ethics, 73 Margaret Ecker 7. Evidence-Based Practice, 83 Patricia A. Stockert UNIT 2 PROCESSES IN NURSING CARE 8. Critical Thinking, 100 Patricia A. Potter 9. Nursing Process, 117 Anne Griffin Perry 10. Informatics and Documentation, 157 Noël Marie Kerr 11. Communication, 178 Susan Hendricks 12. Patient Education, 201 Emily McKenna 13. Managing Patient Care, 221 Amy M. Hall UNIT 3 NURSING PRACTICE FOUNDATIONS 14. Infection Prevention and Control, 235 Lorri A. Graham 15. Vital Signs, 268 Susan Fetzer 16. Health Assessment and Physical Examination, 318 Angela McConachie 17. Medication Administration, 379 Patricia A. Potter 18. Fluid, Electrolyte, and Acid-Base Balances, 479 Linda Felver 19. Complementary, Alternative, and Integrative Therapies, 536 Nancy Laplante UNIT 4 PROMOTING PSYCHOSOCIAL HEALTH 20. Caring in Nursing Practice, 551 Anne Griffin Perry 21. Cultural Competence, 563 Patricia A. Potter 22. Spiritual Health, 578 Patricia A. Stockert 23. Growth and Development, 597 Jerrilee Lamar 24. Self-Concept and Sexuality, 624 Victoria N. Folse 25. Family Dynamics, 644 Amy M. Hall 26. Stress and Coping, 663 Anne Griffin Perry 27. Loss and Grief, 682 Theresa Pietsch UNIT 5 PROMOTING PHYSICAL HEALTH 28. Activity and Exercise, 703 Judith A. McCutchan 29. Immobility, 741 Judith A. McCutchan 30. Safety, 782 Cassandra Horack 31. Hygiene, 812 Anne Griffin Perry 32. Oxygenation, 865 Carolyn Wright Boon 33. Sleep, 917 Patricia A. Stockert 34. Pain Management, 939 Linda Cason 35. Nutrition, 972 Staci McIntosh 36. Urinary Elimination, 1018 Sandra L. Richmond 37. Bowel Elimination, 1059 Jane Fellows 38. Skin Integrity and Wound Care, 1100 Janice C. Colwell 39. Sensory Alterations, 1168 Jill Parsons 40. Surgical Patient, 1187 Anita Shoup
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- 9. N I N T H E D I T I O N Essentials for Nursing Practice Patricia A. Potter, RN, MSN, PhD, FAAN Formerly, Director of Research Patient Care Services Barnes-Jewish Hospital St. Louis, Missouri Anne Griffin Perry, RN, MSN, EdD, FAAN Professor Emerita School of Nursing Southern Illinois University—Edwardsville Edwardsville, Illinois Patricia A. Stockert, RN, BSN, MS, PhD President, College of Nursing Saint Francis Medical Center College of Nursing Peoria, Illinois Amy M. Hall, RN, BSN, MS, PhD, CNE Dean, School of Nursing Franciscan Missionaries of Our Lady University Baton Rouge, Louisiana
- 10. 3251 Riverport Lane St. Louis, Missouri 63043 ESSENTIALS FOR NURSING PRACTICE, NINTH EDITION ISBN 978-0-323-48184-7 Copyright © 2019, Elsevier Inc. All Rights Reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2015, 2011, 2007, 2003, 1999, 1995, 1991, 1987. Herdman, T.H. Kamitsuru, S. (Eds.) Nursing Diagnoses—Definitions and Classification 2012-2014 Copyright © 2014, 1994-2014 NANDA International. Used by arrangement with John Wiley Sons, Inc. In order to make safe and effective judgments using NANDA-I nursing diagnoses, it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in the work. International Standard Book Number: 978-0-323-48184-7 Director: Tamara Myers Content Development Manager: Lisa P. Newton Senior Content Development Specialist: Tina Kaemmerer Publishing Services Manager: Jeff Patterson Senior Project Manager: Jodi M. Willard Design Direction: Paula Catalano Printed in Canada Last digit is the print number: 9 8 7 6 5 4 3 2 1
- 11. v CONTRIBUTORS Carolyn Wright Boon, MSN, BSN Assistant Professor Saint Francis Medical Center College of Nursing Peoria, Illinois Linda Cason, DNP, MSN, BSN Clinical Nurse Specialist Deaconess Hospital, Inc. Evansville, Indiana Lori Catalano, JD, MSN, RN, CCNS, PCCN Assistant Professor of Clinical Nursing College of Nursing University of Cincinnati Cincinnati, Ohio Edith Claros, PhD, MSN, RN, APHN-BC PMHNP Track Coordinator and Associate Professor School of Nursing MCPHS University Worcester, Massachusetts Janice C. Colwell, RN, MS, CWOCN, FAAN Advanced Practice Nurse Surgery University of Chicago Medicine Chicago, Illinois Margaret Ecker, RN, MS Nurse Consultant Los Angeles, California; Director of Nursing Quality, retired Kaiser Permanente Los Angeles Los Angeles, California Jane Fellows, MSN, CWOCN Wound/Ostomy CNS Advanced Clinical Practice Duke University Health System Durham, North Carolina Linda Felver, PhD, RN Associate Professor School of Nursing Oregon Health Science University Portland, Oregon Susan Fetzer, BA, BSN, MSN, MBA, PhD, CNL Professor College of Health and Human Services University of New Hampshire Durham, New Hampshire; Director of Research Patient Care Services Southern New Hampshire Medical Center Nashua, New Hampshire Victoria N. Folse, PhD, APN, PMHCNS-BC, LCPC Director and Professor; Caroline F. Rupert Endowed Chair of Nursing School of Nursing Illinois Wesleyan University Bloomington, Illinois Lorri A. Graham, DNP, RN Associate Professor Saint Francis Medical Center College of Nursing Peoria, Illinois Susan Hendricks, EdD, MSN, RN, CNE Associate Dean for Undergraduate Programs School of Nursing Indiana University Indianapolis, Indiana Cassandra Horack, MS, PSL, BSN Vice President Quality and Safety OSF HealthCare Saint Francis Medical Center Peoria, Illinois Noël Marie Kerr, PhD Assistant Professor School of Nursing Illinois Wesleyan University Bloomington, Illinois Jerrilee Lamar, PhD, RN, CNE Associate Professor of Nursing Dunigan Department of Nursing and Health Sciences University of Evansville Evansville, Indiana Nancy Laplante, PhD, RN, AHN-BC Associate Professor School of Nursing Widener University Chester, Pennsylvania Angela McConachie, FNP, DNP Assistant Professor Faculty Goldfarb School of Nursing at Barnes- Jewish College St. Louis, Missouri Judith A. McCutchan, ASN, BSN, MSN, PhD Adjunct Faculty Nursing University of Evansville Evansville, Indiana Staci McIntosh, MS, RD Assistant Professor (Lecturer) Department of Nutrition and Integrative Physiology University of Utah Salt Lake City, Utah Emily McKenna, APN, CNS INI Neurology OSF HealthCare Saint Francis Medical Center Peoria, Illinois Jill Parsons, PhD, RN Associate Professor Nursing MacMurray College Jacksonville, Illinois Theresa Pietsch, PhD, RN, CRRN, CNE Associate Professor Division of Nursing Health Sciences Neumann University Aston, Pennsylvania Sandra L. Richmond, DNP, MS, RN, CSN Dean, School of Nursing and Health Sciences Pennsylvania College of Technology Williamsport, Pennsylvania Anita Shoup, DNP, RN, CNS-SP, CNOR Assistant Professor; Coordinator, Simulation/Experiential Learning Nursing Heritage University Toppenish, Washington
- 12. vi Contributors and Reviewers Michelle Aebersold, PhD, RN, CHSE, FAAN Clinical Associate Professor and Director of Simulation University of Michigan School of Nursing Ann Arbor, Michigan Lezley Anderson, MA, MSN, RN Assistant Professor Saint Francis Medical Center College of Nursing Peoria, Illinois Colleen Andreoni, DNP, MSN, ANP-BC, FNP-BC Advanced Practice Nurse Board Certified Nurse Practitioner Northwestern Medicine Regional Medical Group Chicago, Illinois Suzanne L. Bailey, PMHCNS-BC, CNE Associate Professor of Nursing University of Evansville Evansville, Indiana Leigh Ann Bonney, PhD, RN, CCRN Associate Professor Saint Francis Medical Center College of Nursing Peoria, Illinois Denise Branchizio, DNP, MSN, RN Assistant Professor of Nursing New Jersey City University Jersey City, New Jersey Anna M. Bruch, RN, MSN Nursing Professor Illinois Valley Community College Oglesby, Illinois Sheryl Buckner, PhD, RN, ANEF Assistant Professor/Lab Director University of Oklahoma Earl and Frances Ziegler College of Nursing Oklahoma City, Oklahoma Pat Callard, DNP, RN, CNL Associate Professor of Nursing College of Graduate Nursing Western University of Health Sciences Pomona, California Kim Clevenger, EdD, MSN, RN, BC Associate Professor of Nursing Morehead State University Morehead, Kentucky Tracy Colburn, RN, MSN, C-EFM Associate Professor of Nursing Lewis and Clark Community College Godfrey, Illinois Barbara A. Coles, PhD, RN-BC, LHRM Adjunct Professor American Public University System Charles Town, West Virginia Janice C. Colwell, RN, MS, CWOCN, FAAN Advanced Practice Nurse Surgery University of Chicago Medicine Chicago, Illinois Pamela Cook, PhD(c), MSN, RN, CNS Assistant Professor Bloomsburg University Bloomsburg, Pennsylvania Eileen Costantinou, MSN, RN-BC Practice Specialist, Senior Coordinator Barnes-Jewish Hospital St. Louis, Missouri Graciela Lopez Cox, MSN, RN Assistant Professor Samuel Merritt University Sacramento, California Pamela A. Dettenmeier, PhD(c), DNP, ANP-BC Associate Professor of Medicine Director CPAP Adherence Clinic Adult Nurse Practitioner Division of Pulmonary, Critical Care Sleep Medicine Saint Louis University St. Louis, Missouri Holly Johanna Diesel, PhD, RN Associate Professor and Academic Chair of the Accelerated and RN to BSN Program Goldfarb School of Nursing at Barnes- Jewish College St. Louis, Missouri Christine R. Durbin, PhD, JD, RN Associate Professor and Chair, Primary Care Health Systems Department Southern Illinois University School of Nursing Edwardsville, Illinois Amber Essman, DNP, MSN, FNP-BC, CNE ARNP Confluence Health; Visiting Professor Chamberlain College of Nursing Moses Lake, Washington Kelly L. Fisher, PhD, RN, FNAP Dean, School of Nursing Endicott College Beverly, Massachusetts Linda R. Garner, PhD, RN, APHN-BC, CHES Associate Professor Southeast Missouri State University Cape Girardeau, Missouri Linda Hansen-Kyle, PhD, RN, CCM Chair (Retired) Second Degree Program Azusa Pacific University Azusa, California; University of San Diego San Diego, California; University of Phoenix Tempe, Arizona Nicole M. Heimgartner, MSN, RN, COI Vice President Connect: RN2ED Dayton, Ohio Kathleen C. Jones, MSN, RN, CNS Associate Professor of Nursing Walters State Community College Morristown, Tennessee Shari Kist, PhD, RN, CNE Associate Professor Goldfarb School of Nursing at Barnes- Jewish College St. Louis, Missouri Kimberly Leppert, MSN, RN, ACNS-BC, CNOR, ONC Surgery Clinical Supervisor Swedish Health Services-Ballard Seattle, Washington Kathryn A. Lever, RN, MSN, WHNP-BC Associate Professor of Nursing Dunigan Family School of Nursing and Health Sciences University of Evansville Evansville, Indiana Mary M. Lopez, PhD, RN Associate Dean, Research Western University of Health Sciences Pomona, California Angela McConachie, DNP, FNP Assistant Professor Goldfarb School of Nursing at Barnes- Jewish Hospital St. Louis, Missouri Janis Longfield McMillan, RN, MSN, CNE Associate Clinical Professor Northern Arizona University Flagstaff, Arizona REVIEWERS
- 13. vii Contributors and Reviewers Pamela Molnar, RN, CEN Decatur Morgan Hospital Decatur, Alabama Katrin Moskowitz, DNP, FNP Doctor of Nursing Practice Meriden, Connecticut Katie Murphy, RN, MSN, PHN Virtual Nurse Educator Quintiles/Abbvie Chicago, Illinois Wendy R. Ostendorf, RN, MS, EdD, CNE Professor of Nursing Neumann University Aston, Pennsylvania Veronica (Ronnie) Peterson, BA, BSN, MS Manager of Clinical Support UW-Medical Foundation Madison, Wisconsin Victoria Plagenz, PhD, MS, BSN Assistant Professor University of Great Falls Great Falls, Montana Melissa Anne Radecki, MSN, NEd, RN, PCCN Nursing Instructor Florida Southern College Lakeland, Florida Cherie R. Rebar, PhD, MBA, RN, COI Affiliate Faculty Indiana Wesleyan University Marion, Indiana; Consultant Xavier University School of Nursing Cincinnati, Ohio Anita K. Reed, MSN, RN Chair, Community Health Practice St. Elizabeth School of Nursing Saint Joseph’s College Lafayette, Indiana Jill R. Reed, PhD, APRN-NP Assistant Professor University of Nebraska Medical Center, College of Nursing Kearney, Nebraska Rhonda J. Reed, MSN, RN, CRRN Learning Resource Center Director— Technology Coordinator Indiana State University Terre Haute, Indiana Maura C. Schlairet, EdD, MA, MSN, RN, CNL Professor of Nursing, Bioethicist College of Nursing and Health Sciences Valdosta State University Valdosta, Georgia Susan Parnell Scholtz, RN, PhD Associate Professor of Nursing Moravian College Bethlehem, Pennsylvania Elizabeth Sibson-Tuan, MS, RN Bay Area Preceptor Coordinator Samuel Merritt University Oakland, California Crystal Slaughter, DNP, APN, ACNS-BC Associate Professor Saint Francis Medical Center College of Nursing Peoria, Illinois Emily G. Smith, DNP, RN, CRRN, CNE, FNAP Assistant Professor Endicott College Beverly, Massachusetts Mindy Stayner, PhD, MSN, RN Professor Northwest State Community College Chamberlain College of Nursing Capella University Archbold, Ohio Laura M. Streeter, BSN, RN, SCRN, GCPH Stroke Program Nurse University of Missouri Health System Columbia, Missouri Linda Turchin, RN, MSN, CNE Associate Professor of Nursing Fairmont State University Fairmont, West Virginia Claudia C. Turner, MSN, RN Professor of Nursing Temple College Temple, Texas Heidi Tymkew, PT, DPT, MHS, CCS Clinical Specialist Barnes-Jewish Hospital St. Louis, Missouri Kim Webb, MN, RN Adjunct Nursing Instructor Pioneer Technology Center Ponca City, Oklahoma Anne M. Welsh, MSN-Ed, RN Assistant Professor Lewis and Clark Community College Godfrey, Illinois Estella J. Wetzel, MSN, APRN, FNP-C Family Nurse Practitioner AANP, OAAPN Dayton, Ohio Laura M. Willis, DNP, APRN, FNP-C Co-President, Connect: RN2ED Beavercreek, Ohio; Family Nurse Practitioner Urbana, Ohio Paige Wimberley, PhD, APRN, CNS, CNE Associate Professor of Nursing Arkansas State University Jonesboro, Arkansas Valerie Yancey, PhD, RN Associate Professor Southern Illinois University Edwardsville Edwardsville, Illinois Jean Yockey, PhD, FNP-BC, CNE Assistant Professor University of South Dakota Vermillion, South Dakota
- 14. viii Contributors and Reviewers CONTRIBUTORS TO PREVIOUS EDITIONS Jeanette Spain Adams, RN, PhD, CRNI, APRN Michelle Aebersold, PhD, RN Elizabeth A. Ayello, RN, BSN, MS, PhD, CS, CETN Marjorie Baier, RN, PhD Sylvia Baird, RN, BSN, MM Brenda A. Battle, MBA, BSN, RN Lois Bentler-Lampe, RN, MS Peggy Breckenridge, MSN, FNP Judith C. Brostron, RN, BA, JD, LLM Victoria M. Brown, RN, BSN, MSN, PhD, HNC Jeri Burger, RN, PhD Gale Carli, MSN, MSHed, BSN, RN Rhonda Comrie, PhD, RN Kelly Jo Cone, RN, BSN, MS, PhD Roslyn Corcoran, RN, BSN Eileen Costantinou, RN, MSN, BC Ruth Curchoe, RN, MSN, CIC Rick Daniels, RN, BSN, MSN, PhD Carolyn Ruppel D’Avis, RN, BSN, MSN Christine Durbin, RN, JD, PhD Sharon J. Edwards, RN, BSN, MSN, PhD Martha Keene Elkin, RN, MSN, IBCLC Linda Fasciani, RN, BSN, MSN Susan J. Fetzer, RN, BA, BSN, MSN, MBA, PhD Leah Frederick, MS, RN, CIC Cynthia S. Goodwin, RN, BSN, MSN Lois C. Hamel, BS, MS Janis Waite Hayden, RN, EdD Maureen Huhmann, MS, RD Tara Hulsey, RN, PhD, CNE, FAAN Judith Ann Kilpatrick, RN, MSN, DNSc Carl A. Kirton, RN-C, BSN, MA, ACRN, ANP Lori Klingman, RN, MSN Kristine L’Ecuyer, RN, MSN, CCNS Kathryn A. Lever, RNC, MSN, WHNP-BC Ruth Ludwick, RN, BSN, MSN, PhD, RN-C Suzanne Lugerner, RN, MS, LN, CNSC, CNS Mary Kay Knight Macheca, RN, BSN, MSN(R), CS, CDE Deborah L. Marshall, RN, MSN Carol McGinnis, DNP, RN, CNS, CNSC Rita G. Mertig, RNC, MS, CNS Mary Dee Miller, RN, BSN, MS, CIC Elaine Neel, BSN, MSN Geralyn A. Ochs, RN, ADN, BSN, MSN Marsha Evans Orr, RN, MS, CS, CNSN Wendy R. Ostendorf, MS, EdD Dula F. Pacquiao, EdD, RN, CTN Nancy Panthofer, RN, BSN, MSN Elizabeth S. Pratt, RN, MSN, ACNS-BC Julia Balzer Riley, RN, MN, AHN-C, CET® Kristine A. Rose, RN, MSN Janice J. Rumfelt, BSN, MSN, EdD, RNC Marilyn Schallom, MSN, CCRN, CCNS Matthew R. Sorenson, RN, PhD Sharon Souter, RN, BSN, MSN Elizabeth Speakman, RN, EdD Rachel E. Spector, BS, MS, PhD, CTN, FAAN Susan Speraw, RN, PHD, CNP Donna L. Thompson, MSN, CRNP, FNP-BC, CCCN Jelena Todic, MSW, LCSW Riva Touger-Decker, PhD, RD, FADA Ann Tritak, RN, EdD Ellen Wathen, PhD, RN, BC Pamela Becker Weilitz, DNP, APRN, ANP-BC Joan Domigan Wentz, MSN, RN Paige Wimberley, PhD, APN, CNS, CNE Terry L. Wood, PhD, RN, CNE Rita Wunderlich, PhD, RN, CNE Valerie Yancey, RN, PhD Barbara Yoost, RN, BSN, MSN, CNS
- 15. I wish to dedicate this edition of Essentials to the many friends who make up my family. Each one contributes in so many ways to support and value the work I am able to do. Special thanks to Ruth, a wonderful listener and advocate; Jim, a valued friend and kind man; Bess, always adding humor and love to my life; and Anne, a consummate writing colleague and lifelong mentor. Patricia A. Potter To all nursing faculty and professional nurses who work each day to advance clinical nursing. Your commitment to nursing education and nursing practice inspires us all to be the guardians of the discipline. I also want to thank my husband Bob for his loving support. Anne Griffin Perry I was blessed to have an incredible nursing role model in my life—my mother, Evelyn M. Clark, RN. Your dedication and service to nursing inspired me to pursue my career as a professional nurse. Your unwavering support of my endeavors provided a foundation for me to continue to grow in my nursing role. Your encouragement and pride in my accomplishments was tremendous. Thank you for starting me on my path to a long and satisfying career in nursing and nursing education. I love you and miss you! Patricia A. Stockert To my family, especially Greg, Jacob, Isaac, and Mom and Dad. Thank you for your love, support, and patience, without which I would not be able to chase my dreams. Thank you also to the nursing faculty at Franciscan Missionaries of Our Lady University. Your never-ending compassion and commitment to nursing education inspires me every day. And finally, to my Varsity Sports running friends, who keep me grounded and who have helped me integrate into my new community. Despite all those really hot and long runs, y’all haven’t killed me yet! Amy M. Hall
- 16. x P R E F A C E T O T H E I N S T R U C T O R The nursing profession is always responding to dynamic change and continual challenges. Today’s nurses must be pre- pared to adapt to the continual changes occurring in health care. They play a vital role in the delivery of multidisciplinary health care services. The practice arena is changing—moving more to the community setting. The focus of care is also changing, with more emphasis being placed on health pro- motion and restorative care. Even the patients are chang- ing—more cultural diversity exists, and the percentage of older adult patients continues to increase. Patients are far more involved in and informed about health care. Despite—or perhaps because of—these changes,it is essen- tial that the basics of nursing remain the foundation of prac- tice. Nurses must be knowledgeable and professional. They must be both technically proficient and personally caring. And they must be able to synthesize a broad array of knowl- edge and experience when providing care for their patients. We continue to cover all of the fundamental nursing con- cepts, skills, and techniques that students must master before moving on to other areas of study. In addition, we address changes in practice that affect how and where nurses use the skills and knowledge they acquire. FEATURES We have designed this text to welcome the new student to nursing, communicate our own love for the profession, and promote learning and understanding. We know that today’s students are busy and, too often, are overwhelmed by all that they must learn and do. They want their texts to focus on the most current, factual, and essential content and skills. We want to ensure that these students are ready to continue with their education and will ultimately be prepared for all of the challenges of practice. To this end, we have included the fol- lowing key features: • Students will appreciate the clear, engaging writing style. The narrative actually addresses the reader, making this textbook more of an active instructional tool than a passive reference. Students will find that even complex technical and theoretical concepts are presented in a language that is easy to understand. • The attractive, functional design will appeal to today’s visual learner. The clear, readable type and bold headings make the content easy to read and follow. Each special element is consistently color keyed so students can readily identify important information. • Hundreds of large, clear, full-color photographs and drawingsreinforceandclarifykeyconceptsandtechniques. • The five-step nursing process serves as the organizing framework for all clinical chapters. This logical, consistent framework for narrative discussions is further enhanced by special boxes that highlight assessment, care plans, and evaluation of outcome achievement. • Ongoing case studies in each chapter introduce “real- world” patients, families, and nurses. The chapter follows the case study through the steps of the nursing process, helping students see how to apply the process, as well as critical thinking, to the care of patients. Cases take place in both acute and community settings and include patients and nurses from a variety of cultural backgrounds. • Nursing Care Plans guide students on how to conduct an assessment and analyze the defining characteristics that indicate nursing diagnoses. The plans include NIC and NOC classifications to familiarize students with this important nomenclature. The evaluation sections of the plans show students how to evaluate and then determine the outcomes of care. • Concept Maps included in clinical chapters show you the associations among multiple nursing diagnoses for a patient with a selected medical diagnosis, as well as their relationship to nursing interventions. • The implementation narrative consistently addresses health promotion, acute care, and restorative and continu- ing care to reflect a focus on community-based nursing and health promotion. • Information related to the Quality and Safety Education for Nurses (QSEN) initiative is highlighted with activities integrated into each chapter. These activities incorporate one of the six key competencies and relate back to the progressive chapter case study scenarios. • More than 35 nursing skills are presented in a clear, two- column format with steps and rationales. Skills include delegation guidelines and clinical decision points that alert students to steps that require special assessment or specific technique for safe and effective administration. • Procedural guidelines provide streamlined step-by-step instructions for performing very basic skills. • Care of the older adult and patient teaching are stressed throughout the narrative and are also highlighted in special boxes. • Learning aids to help students identify, review, and apply important content in each chapter include Objectives, Key Terms, Key Points, and Review Questions. • Printed lists on the inside back cover provide information on locating specific assets in the book, including Skills, Procedural Guidelines, Nursing Care Plans, and Patient Teaching boxes. New to This Edition • A new chapter on “Complementary, Alternative, and Integrative Therapies” addresses content that is now included on the NCLEX® examination. • A new Reflective Learning section in each chapter helps students better understand and reflect on their clinical and simulation experiences as they move through their first nursing course. • Evidence-Based Practice boxes have been updated with new PICO questions. These boxes provide a summary of nursing research evidence related to that specific topic and then explain its implications for nursing practice. These
- 17. xi Preface to the Instructor boxes have been updated to reflect current research topics and trends. LEARNING SUPPLEMENTS FOR STUDENTS • The Evolve Student Resources are available online at http://evolve.elsevier.com/Potter/essentials and include the following valuable learning aids organized by chapter: • Review Questions with Answers and Rationales • Answers to QSEN Activity Scenarios • Case Studies with Questions • Printable Key Points • Video Clips • Interactive Skills Performance Checklists • Fluids and Electrolytes Tutorial • Audio Glossary • Concept Map Creator • Conceptual Care Map • Calculation Tutorial • Answers to Student Study Guide • Content Updates • A thorough Study Guide by Patricia A. Castaldi provides students with a wide variety of exercises and activities to enhance learning and comprehension. This study guide features case studies with related questions; chapter review sections with matching, fill-in-the-blank, and multiple- choice questions; study group questions; and instructions for creating and using study charts. • Virtual Clinical Excursions is an exciting workbook and CD-ROM experience that brings learning to life in a virtual hospital setting. The workbook guides stu- dents as they care for patients, providing ongoing chal- lenges and learning opportunities. Each lesson in Virtual Clinical Excursions complements the textbook content and provides an environment for students to practice what they are learning. This CD/workbook is avail- able separately or packaged at a special price with the textbook. TEACHING SUPPLEMENTS FOR INSTRUCTORS • The Evolve Instructor Resources (available online at http://evolve.elsevier.com/Potter/essentials) are a compre- hensive collection of the most important tools instructors need, including the following: • TEACH for Nurses ties together every chapter resource you need for the most effective class presentations, with sections dedicated to objectives, teaching strategies, nursing curriculum standards (including QSEN/NLN Competencies, BSN Essentials, and Nursing Concepts), instructor chapter resources, student chapter resources, and an in-class case study discussion. Teaching Strate- gies include relationships between the textbook content and discussion items. Examples of student activities, online activities, and large group activities are provided for more “hands-on” learning. • The Test Bank contains a revised set of more than 950 questions with answers coded for NCLEX® Client Needs category,nursing process,and cognitive level.The Exam- View software allows instructors to create new tests; edit, add,and delete test questions;sort questions by NCLEX® category, cognitive level, nursing process step, and ques- tion type; and administer and grade online tests. • PowerPoint Presentations include over 1400 slides for use in lectures. Art is included within the slides, and progressive case studies include discussion questions and answers. • The Image Collection contains hundreds of illustra- tions from the text for use in lectures. • Simulation Learning System is an online toolkit that helps instructors and facilitators effectively incorporate medium- to high-fidelity simulation into their nursing curriculum. Detailed patient scenarios promote and enhance the clini- cal decision-making skills of students at all levels. The system provides detailed instructions for preparation and implementation of the simulation experience, debriefing questions that encourage critical thinking, and learning resources to reinforce student comprehension. Each sce- nario in Simulation Learning System complements the text- book content and helps bridge the gap between lectures and clinicals. This system provides the perfect environment for students to practice what they are learning in the text for a true-to-life, hands-on learning experience. MULTIMEDIA SUPPLEMENTS FOR INSTRUCTORS AND STUDENTS • Nursing Skills Online 4.0 contains 19 modules rich with animations, videos, interactive activities, and exercises to help students prepare for their clinical lab experience. The instructionally designed lessons focus on topics that are difficult to master and pose a high risk to the patient if done incorrectly. Lesson quizzes allow students to check their learning curve and review as needed, and the module exams feed out to an instructor grade book. Modules cover Airway Management, Blood Therapy, Bowel Elimination/ Ostomy, Cardiac Care, Closed Chest Drainage Systems, Enteral Nutrition, Infection Control, Maintenance of IV Fluid Therapy, IV Fluid Therapy, Administration of Par- enteral Medications: Injections and IV Medications, Non- parenteral Medication Administration, Safe Medication Preparation, Safety, Specimen Collection, Urinary Cathe- terization, Caring for Central Vascular Access Devices (CVAD), Vital Signs, and Wound Care. Available alone or packaged with the text. • Mosby’s Nursing Video Skills: Basic, Intermediate, Advanced, 4th edition, provides 126 skills with overview information covering skill purpose, safety, and delegation guides;equipment lists;preparation procedures;procedure videos with printable step-by-step guidelines; appropriate follow-up care; documentation guidelines; and interactive review questions. Available online, as a student DVD set, or as a networkable DVD set for the institution.
- 18. xii A C K N O W L E D G M E N T S The ninth edition of Essentials for Nursing Practice is the result of a continued collaboration among all authors, con- tributors, and editorial team members. Having professional colleagues to work with, trust, and challenge one another is a gift—one that ensures a timely and accurate text. This textbook cannot be created without the support, guidance, and creative direction from our editorial team, designer, and production staff. Likewise, no book is successful without the hard work and dedication of its marketing team. We are also very fortunate regarding the manner in which staff from the electronic media division of Elsevier has pro- duced products that complement the text and ensure its success. We wish to make special mention of some important individuals. Tamara Myers, Director, is a dedicated professional who continually challenges the author team to create a state-of- the-art revision. Her enthusiasm and knowledge creates an environment for the writing, editorial, and production teams to develop a relevant and creative textbook that reflects con- temporary nursing practice. Tina Kaemmerer, Senior Content Development Specialist, is a dedicated professional whose organizational skills ensure that this project remains on target. She effectively collaborates with all members of the writing team in tracking manuscript through the publication process, in problem solving, and in being an invaluable resource for authors, contributors, and the production team. Paula Catalano, our Book Designer, has developed a visu- ally distinctive textbook design. Her expertise created a text that is visually appealing yet easy for our readers to use. Paula is also credited for her creativity and vision for the design of the cover art and her direction in implementing the overall design of the text. Many thanks and gratitude go to members of the Produc- tion Team. Jodi Willard, Senior Project Manager, is a tireless and dedicated professional. As an accomplished project manager, she keeps us on deadline while ensuring consistency in formatting, presentation, and style. Her sense of humor and ability to always remain calm under pressure are invalu- able attributes. She is one of a kind. Jeff Patterson, Publishing Services Manager, has contributed support throughout the editing and final pages. A tip of the hat must always go to the sales and marketing team, headed by Julie Burchett and Megan Atencio, who pro- vided us direction early in the planning stage of Essentials for Nursing Practice. Their knowledge of market trends and needs helps us to make revisions of high quality. Many thanks to our contributors, clinicians, and edu- cators, who share their experiences and knowledge about nursing practice in helping to create informative, accu- rate, and current information. Their knowledge of their own clinical specialties ensures we have a state-of-the-art textbook. We are fortunate to be associated with excellent nurse authors who are able to convey standards of nursing excellence through the printed word. A heartfelt thanks to our many reviewers for their exper- tise, candor, knowledge of the literature, and astute com- ments that assist us in developing a text with high standards that reflect professional nursing practice today. After many years of collaboration, we find ourselves very fortunate and humble. Essentials for Nursing Practice and the other textbooks we have been able to develop have made important contributions to nursing practice. It remains a work of love. Patricia A. Potter Anne Griffin Perry Patricia A. Stockert Amy M. Hall
- 19. xiii C O N T E N T S UNIT 1 CONCEPTS IN NURSING 1 Professional Nursing, 1 Patricia A. Stockert History of Nursing, 2 Influences on Nursing, 3 Professionalism, 5 Nursing Practice, 7 Standards of Nursing Practice, 7 Responsibilities and Roles of the Nurse, 8 Professional Nursing Organizations, 10 Trends in Nursing, 10 2 Health and Wellness, 15 Amy M. Hall Definition of Health, 15 Models of Health and Illness, 16 Healthy People Documents, 19 Variables Influencing Health Beliefs and Health Practices, 19 Health Promotion, Wellness, and Illness Prevention, 20 Illness, 24 Impact of Illness on Patient and Family, 25 The Nurse’s Role in Health and Illness, 26 3 The Health Care Delivery System, 29 Patricia A. Potter Traditional Levels of Health Care, 30 Health Care Costs and Quality, 40 Issues in Health Care Delivery for Nursing, 42 4 Community-Based Nursing Practice, 48 Edith Claros Achieving Healthy Populations and Communities, 49 Public Health Nursing, 50 Community Health Nursing, 50 Community-Based Nursing, 51 Competency in Community-Based Nursing, 53 Community Assessment, 55 Changing Patients’ Health, 56 5 Legal Principles in Nursing, 59 Lori Catalano Legal Limits of Nursing, 60 Standards of Care, 62 Good Samaritan Laws, 64 Consent, 65 Other Legal Issues in Nursing Practice, 68 6 Ethics, 73 Margaret Ecker Ethics, 73 Ethical Theory, 77 How to Process an Ethical Dilemma, 78 Ethical Issues in Nursing, 79 Conclusion, 80 7 Evidence-Based Practice, 83 Patricia A. Stockert A Case for Evidence-Based Practice, 84 Evidence-Based Practice Steps, 85 Nursing Research, 93 Quality Improvement and Performance Improvement, 95 Relationship Between Evidence-Based Practice, Research, and Quality Improvement, 96 UNIT 2 PROCESSES IN NURSING CARE 8 Critical Thinking, 100 Patricia A. Potter Clinical Judgment in Nursing Practice, 101 Levels of Critical Thinking in Nursing, 103 Critical Thinking Competencies, 105 Critical Thinking Model, 108 Critical Thinking Synthesis, 114 9 Nursing Process, 117 Anne Griffin Perry Introduction, 118 Assessment, 119 Nursing Diagnosis, 126 Planning, 135 Implementation, 146 Evaluation, 151 10 Informatics and Documentation, 157 Noël Marie Kerr Health Care Informatics, 158 Nursing Information Systems, 159 Confidentiality of Medical Record and Patient Information, 160 Interprofessional Communication Within the Health Care Team, 162 Purposes of Records, 163 Guidelines and Standards for Quality Nursing Documentation, 165 Methods of Documentation, 167 Common Record-Keeping Forms, 169 Documentation in Home Care Settings, 172 Documentation in Long-Term Care Settings, 172 Reporting, 173
- 20. xiv Contents 11 Communication, 178 Susan Hendricks The Power of Communication, 179 Basic Elements of the Communication Process, 179 Levels of Communication, 180 Forms of Communication, 180 Factors Influencing Communication, 182 Communication Within Caring Relationships, 187 Communication Within the Nursing Process, 189 12 Patient Education, 201 Emily McKenna Standards for Patient Education, 202 Purposes of Patient Education, 202 Teaching and Learning, 203 Domains of Learning, 204 Basic Learning Principles, 205 Integrating Nursing and Teaching Processes, 208 Documentation of Patient Teaching, 218 13 Managing Patient Care, 221 Amy M. Hall Building a Nursing Team, 222 Nursing Care Delivery Models, 223 Decision Making, 224 Leadership Skills for Nursing Students, 227 UNIT 3 NURSING PRACTICE FOUNDATIONS 14 Infection Prevention and Control, 235 Lorri A. Graham Scientific Knowledge Base, 236 Nursing Knowledge Base, 241 Critical Thinking, 242 Nursing Process, 242 15 Vital Signs, 268 Susan Fetzer Guidelines for Measuring Vital Signs, 269 Body Temperature, 270 Pulse, 276 Blood Pressure, 280 Respiration, 288 Measurement of Oxygen Saturation (Pulse Oximetry), 289 Measurement of End-Tidal Carbon Dioxide, 289 Special Considerations, 290 Documenting Vital Signs, 291 Skill 15.1 Measuring Body Temperature, 292 Skill 15.2 Assessing Radial and Apical Pulses, 299 Skill 15.3 Blood Pressure Measurement, 303 Skill 15.4 Assessing Respiration, 309 Skill 15.5 Measuring Oxygen Saturation (Pulse Oximetry), 313 16 Health Assessment and Physical Examination, 318 Angela McConachie Purposes of Health Assessment and Physical Examination, 319 Cultural Sensitivity, 319 Integration of Physical Assessment With Nursing Care, 320 Skills of Physical Examination, 320 Preparation for Examination, 321 Organization of the Examination, 325 Skin, Hair, and Nails, 328 Head and Neck, 333 Thorax and Lungs, 343 Heart, 348 Vascular System, 351 Breasts, 355 Abdomen, 360 Female Genitalia and Reproductive Tract, 363 Male Genitalia, 365 Rectum and Anus, 368 Musculoskeletal System, 369 Neurological System, 371 After the Examination, 375 17 Medication Administration, 379 Patricia A. Potter Scientific Knowledge Base, 380 Nursing Knowledge Base, 390 Critical Thinking, 400 Nursing Process, 404 Oral Administration, 412 Topical Medication Applications, 413 Parenteral Administration of Medications, 424 Skill 17.1 Administering Oral Medications, 439 Skill 17.2 Administering Eye (Ophthalmic) Medications, 445 Skill 17.3 Using Metered-Dose or Dry Powder Inhalers, 448 Skill 17.4 Preparing Injections From Vials and Ampules, 453 Skill 17.5 Administering Injections, 457 Skill 17.6 Administering Medications by Intravenous Bolus, 463 Skill 17.7 Administering Intravenous Medications by Piggyback, Intermittent Infusion Sets, and Mini-Infusion Pumps, 468 18 Fluid, Electrolyte, and Acid-Base Balances, 479 Linda Felver Scientific Knowledge Base, 480 Nursing Knowledge Base, 489
- 21. xv Contents Critical Thinking, 489 Nursing Process, 490 Skill 18.1 Initiating Intravenous Therapy, 509 Skill 18.2 Regulating Intravenous Flow Rate, 521 Skill 18.3 Changing Intravenous Solution and Tubing, 526 Skill 18.4 Changing a Peripheral Intravenous Dressing, 530 19 Complementary, Alternative, and Integrative Therapies, 536 Nancy Laplante Complementary, Alternative, and Integrative Approaches to Health, 537 Nursing-Accessible Therapies, 540 Training-Specific Therapies, 543 Integrative Nursing Role, 548 UNIT 4 PROMOTING PSYCHOSOCIAL HEALTH 20 Caring in Nursing Practice, 551 Anne Griffin Perry Theoretical Views on Caring, 552 Patient Satisfaction, 555 Caring in Nursing Practice, 557 The Challenge of Caring, 560 21 Cultural Competence, 563 Patricia A. Potter Health Disparities, 564 Racial, Ethnic, and Cultural Identity, 566 World View, 566 Disease and Illness, 567 A Model of Cultural Competence, 568 Cultural Skill, 570 Cultural Encounter, 575 Cultural Desire, 575 22 Spiritual Health, 578 Patricia A. Stockert Scientific Knowledge Base, 579 Nursing Knowledge Base, 579 The Effect of Illness on Spirituality, 581 Critical Thinking, 583 Nursing Process, 585 23 Growth and Development, 597 Jerrilee Lamar Scientific Knowledge Base, 597 Nursing Knowledge Base, 600 Critical Thinking, 615 Nursing Process, 616 24 Self-Concept and Sexuality, 624 Victoria N. Folse Scientific Knowledge Base, 624 Nursing Knowledge Base, 625 Critical Thinking, 632 Nursing Process, 633 25 Family Dynamics, 644 Amy M. Hall Scientific Knowledge Base, 645 Nursing Knowledge Base, 647 Critical Thinking, 650 Nursing Process, 651 26 Stress and Coping, 663 Anne Griffin Perry Scientific Knowledge Base, 664 Nursing Knowledge Base, 668 Critical Thinking, 670 Nursing Process, 671 27 Loss and Grief, 682 Theresa Pietsch Scientific Knowledge Base, 683 Nursing Knowledge Base, 685 Critical Thinking, 687 Nursing Process, 688 UNIT 5 PROMOTING PHYSICAL HEALTH 28 Activity and Exercise, 703 Judith A. McCutchan Scientific Knowledge Base, 704 Nursing Knowledge Base, 707 Critical Thinking, 709 Nursing Process, 710 Skill 28.1 Promoting Early Activity and Exercise, 726 Skill 28.2 Using Safe and Effective Transfer Techniques, 730 29 Immobility, 741 Judith A. McCutchan Scientific Knowledge Base, 742 Nursing Knowledge Base, 746 Critical Thinking, 747 Nursing Process, 748 Skill 29.1 Moving and Positioning Patients in Bed, 771 30 Safety, 782 Cassandra Horack Scientific Knowledge Base, 785 Nursing Knowledge Base, 787 Critical Thinking, 790
- 22. xvi Contents Nursing Process, 791 Skill 30.1 Applying Physical Restraints, 804 31 Hygiene, 812 Anne Griffin Perry Scientific Knowledge Base, 813 Nursing Knowledge Base, 815 Critical Thinking, 817 Nursing Process, 817 Skill 31.1 Bathing and Perineal Care, 851 32 Oxygenation, 865 Carolyn Wright Boon Scientific Knowledge Base, 866 Nursing Knowledge Base, 874 Critical Thinking, 876 Nursing Process, 877 Skill 32.1 Suctioning, 898 Skill 32.2 Care of Patients With Chest Tubes, 907 33 Sleep, 917 Patricia A. Stockert Scientific Knowledge Base, 917 Nursing Knowledge Base, 921 Critical Thinking, 924 Nursing Process, 925 34 Pain Management, 939 Linda Cason Scientific Knowledge Base, 940 Nursing Knowledge Base, 944 Critical Thinking, 946 Nursing Process, 947 Skill 34.1 Patient-Controlled Analgesia, 965 35 Nutrition, 972 Staci McIntosh Scientific Knowledge Base, 973 Nursing Knowledge Base, 976 Critical Thinking, 980 Nursing Process, 980 Skill 35.1 Aspiration Precautions, 1000 Skill 35.2 Inserting a Nasogastric or Nasointestinal Feeding Tube, 1003 Skill 35.3 Administering Enteral Nutrition Via Nasoenteric, Gastrostomy, or Jejunostomy Tubes, 1009 36 Urinary Elimination, 1018 Sandra L. Richmond Scientific Knowledge Base, 1019 Nursing Knowledge Base, 1024 Critical Thinking, 1024 Nursing Process, 1025 Skill 36.1 Inserting and Removing Straight/ Intermittent or Indwelling Catheters, 1046 37 Bowel Elimination, 1059 Jane Fellows Scientific Knowledge Base, 1059 Nursing Knowledge Base, 1061 Critical Thinking, 1065 Nursing Process, 1067 Skill 37.1 Inserting and Maintaining a Nasogastric Tube for Gastric Decompression, 1084 Skill 37.2 Administering a Cleansing Enema, 1091 Skill 37.3 Pouching an Ostomy, 1095 38 Skin Integrity and Wound Care, 1100 Janice C. Colwell Scientific Knowledge Base, 1101 Nursing Knowledge Base, 1108 Critical Thinking, 1108 Nursing Process, 1112 Skill 38.1 Assessment of Patient for Pressure Injury: Risk and Skin Assessment, 1138 Skill 38.2 Treating Pressure Injuries, 1144 Skill 38.3 Negative-Pressure Wound Therapy, 1150 Skill 38.4 Applying Dressings: Dry, Damp-to-Dry, and Transparent, 1154 Skill 38.5 Performing Wound Irrigation, 1161 39 Sensory Alterations, 1168 Jill Parsons Scientific Knowledge Base, 1168 Nursing Knowledge Base, 1170 Critical Thinking, 1172 Nursing Process, 1173 40 Surgical Patient, 1187 Anita Shoup Scientific Knowledge Base, 1188 Nursing Knowledge Base, 1191 Critical Thinking, 1192 PREOPERATIVE SURGICAL PHASE, 1192 Nursing Process, 1193 INTRAOPERATIVE SURGICAL PHASE, 1209 Nurse’s Role During Surgery, 1209 Nursing Process, 1210 POSTOPERATIVE SURGICAL PHASE, 1214 Recovery, 1214 Postanesthesia Care in Ambulatory Surgery, 1214 Recovery Phase, 1214 Nursing Process, 1215 Skill 40.1 Teaching Postoperative Exercises, 1228
- 23. 1 C H A P T E R 1 Professional Nursing MEDIA RESOURCES http://evolve.elsevier.com/Potter/essentials • Audio Glossary • QSEN Activity and Review Questions Answers O B J E C T I V E S • Discuss the characteristics of professionalism in nursing. • Discuss the importance of education in professional nursing practice. • Describe the purpose of professional standards of nursing practice. • Describe the roles and career opportunities for nurses. • Discuss the influence of social, political, and economic changes on nursing practices. K E Y T E R M S advanced practice registered nurse (APRN), p. 9 American Nurses Association (ANA), p. 2 caregiver, p. 8 certified nurse-midwife (CNM), p. 9 certified registered nurse anesthetist (CRNA), p. 9 clinical nurse specialist (CNS), p. 9 code of ethics, p. 6 continuing education, p. 6 genomics, p. 11 in-service education, p. 6 International Council of Nurses (ICN), p. 10 licensed practical nurse (LPN), p. 5 licensed vocational nurse (LVN), p. 5 National League for Nursing (NLN), p. 10 nurse administrator, p. 10 nurse educator, p. 9 nurse practitioner (NP), p. 9 nurse researcher, p. 10 nursing, p. 2 patient advocate, p. 8 professional organization, p. 10 Quality and Safety Education for Nurses (QSEN), p. 10 registered nurse (RN), p. 5 Nursing is an art and a science. As a professional nurse, you learn to deliver care artfully with compassion, caring, and respect for each patient’s dignity and person- hood. As a science, nursing practice is based on a body of knowledge that is continually changing with new discoveries and innovations. When you integrate the science and art of nursing into your practice, the quality of care you provide to your patients is at a level of excellence that benefits patients and their families. Your patients’ health care needs are multidimensional. Thus, your care reflects patients’ needs as well as the needs and values of society and pro- fessional standards of care. In addition, your care should integrate evidence-based practices to provide the highest level of care. The patient is the center of your practice. The patient includes the individual, family, and/or community. Patients have a wide variety of health care needs, experiences, vulner- abilities, and expectations; this is what makes nursing both challenging and rewarding. Making a difference in your patients’ lives is fulfilling. For example, you help a dying patient find relief from pain, help a young mother learn par- enting skills, or find ways for older adults to remain indepen- dent in their homes. Nursing offers personal and professional rewards every day.
- 24. 2 UNIT 1 Concepts in Nursing clinical experience. Your ability to interpret clinical situations and make complex decisions is the foundation for your nursing care and the basis for the advancement of nursing practice and the development of nursing science (Benner, 1984; Benner et al., 1997; Benner et al., 2010). Clinical exper- tise takes time and commitment. Critical thinking skills are essential to nursing (see Chapter 8). When providing nursing care, you need to make clinical judgments and decisions about your patients’ health care needs based on knowledge, experience, and standards of care. Critical thinking and reflection help you gain and interpret scientific knowledge, integrate knowledge from clinical experiences, and become a lifelong learner (Benner et al., 2010). This includes integrat- ing knowledge from basic science and nursing knowledge bases, applying knowledge from past and present experiences, applying critical thinking attitudes to a clinical situation, and implementing intellectual and professional standards (see Chapter 8). When you provide well-thought-out care with compassion and caring, you provide each of your patients the best of the science and art of nursing care (see Chapter 7). HISTORY OF NURSING Since the beginning of the profession, nurses have studied and tested new and better ways to help patients. Patients are most vulnerable when they are injured, sick, or dying. Today nurses are active in determining the best practices for patient care related to problems such as skin care management, pain control, nutritional management, and care of older adults. Nurse researchers are leaders in expanding knowledge in nursing and other health care disciplines. Their work pro- vides evidence for practice to ensure that we have the best available evidence to support our practices (see Chapter 7). Nurses are also active in social policy and political arenas. With their professional organizations, they lobby for health care legislation. For example, nurses have lobbied for laws promoting smoke-free environments and stronger anti- tobacco laws, setting up anti-gang coalitions, establishing safer environments for walking and physical fitness in their communities, and advocating for breastfeeding (Mason et al., 2016). Knowledge of the history of the nursing profession increases your ability to understand the social and intellectual origins of the discipline. Although it is not practical to describe all the historical aspects of professional nursing, some of the more significant milestones are described in the following paragraphs. Florence Nightingale In Notes on Nursing: What It Is and What It Is Not, Florence Nightingale established the first nursing philosophy based on health maintenance and restoration (Nightingale, 1860). She saw the role of nursing as having “charge of somebody’s health” based on the knowledge of “how to put the body in such a state to be free of disease or to recover from disease” (Nightingale, 1860). She developed the first organized train- ing program for nurses in 1860, the Nightingale Training As a nurse, you can choose a variety of career paths includ- ingclinicalpractice,education,research,management,admin- istration, and entrepreneurship. As a student, it is important for you to understand the scope of nursing practice and how nursing influences the lives of your patients. You are required to provide nursing care according to standards of practice and follow a code of ethics (ANA, 2015a; Fowler, 2015b). Profes- sional practice includes knowledge from social and behavioral sciences, biological and physiological sciences, and nursing theories.Inaddition,nursingpracticeincorporatesethicaland social values, professional autonomy, and a sense of commit- ment and community. The American Nurses Association (ANA) defines nursing as the protection, promotion, and opti- mization of health and abilities; prevention of illness and injury; facilitation of healing; alleviation of suffering through the diag- nosis and treatment of human response; and advocacy in the care of individuals, families, groups, communities, and popula- tions (ANA, 2015a). The International Council of Nurses (ICN) (2016) has another definition: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health; prevention of illness; and the care of ill, disabled, and dying people. Advocacy, promo- tion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. Both definitions support the importance that nursing holds in providing safe, patient-centered health care to the global community. Expert clinical nursing practice is a commitment to the application of knowledge, ethics, standards of practice, and Lucas is a nursing student assigned to provide care for a 52-year-old patient, Mr. Thompson, at the residential hospice home. Mr. Thompson came to the hospice home with meta- static pancreatic cancer. Lucas focused his nursing care plan on comfort care for Mr. Thompson. Mrs. Thompson told Lucas that she was worried that her husband would be experiencing pain. This morning Lucas is participating in the interdisciplinary team meeting to discuss Mr. Thompson’s care management. CASE STUDY Lucas Copyright © sturti/Getty Images.
- 25. 3 CHAPTER 1 Professional Nursing (AORN), Infusion Nurses Society (INS), and Emergency Nurses Association (ENA) created. In 1990 the ANA estab- lished the Center for Ethics and Human Rights (see Chapter 6). The Center provides a forum to address the complex ethical and human rights issues confronting nurses and designs programs to increase ethical competence in nurses (Fowler, 2015b). Twenty-First Century Today the nursing profession faces multiple challenges. Nurses and nurse educators are revising nursing practice and school curricula to meet the ever-changing needs of society including bioterrorism, emerging infections, and disaster management. Advances in technology and informat- ics (see Chapter 10), the aging population, the high-acuity level of care of hospitalized patients, and early discharge from health care institutions require nurses in all settings to have a strong and current knowledge base. In addition, nursing and the Robert Wood Johnson Foundation are taking a leadership role in developing standards and policies for end-of-life care through the Last Acts Campaign (see Chapter 27). The End-of-Life Nursing Education Consor- tium (ELNEC) offered collaboratively by the American Association of Colleges of Nursing (AACN) and the City of Hope Medical Center has brought end-of-life care and practices into nursing curricula and professional continuing education programs for practicing nurses (AACN, 2016). INFLUENCES ON NURSING Multiple external forces affect nursing today including health care reform and costs, demographic changes of the popula- tion, increasing numbers of medically underserved individu- als, need for emergency preparedness, workplace issues, and the nursing shortage. Health Care Reform and Costs Health care reform affects how health care is paid for and delivered. In the future there will be greater emphasis on health promotion, disease prevention, and illness manage- ment. More services will be provided in community-based care settings. As a result, more nurses will be needed to prac- tice in community care centers, patients’ homes, schools, and senior centers. This will require expert nurses to assess for resources, service gaps, and how patients adapt to return to their communities. Nursing needs to respond by assessing for resources, changing nursing education, helping patients adapt to new health care delivery methods, and providing care to safely return patients to their homes. Skyrocketing health care costs present challenges to the profession, consumer, and health care delivery system. As a nurse you are responsible for providing the patient with the best-quality care in an efficient and economically sound manner including following established protocols, exercising timely well-planned patient discharge from a care setting, and judiciously using supplies and equipment. The challenge is to use health care and patient resources wisely. Chapter 3 School for Nurses at St. Thomas’ Hospital in London. Nightingale volunteered during the Crimean War in 1853 and traveled the battlefield hospitals at night carrying her lamp; thus she was known as the “lady with the lamp.” As a result of Nightingale’s organization and improvement of the sanita- tion facilities at the battlefield hospitals, the mortality rate at the Barracks Hospital in Scutari, Turkey, was reduced from 42.7% to 2.2% in 6 months (Donahue, 2011). Perhaps one of Nightingale’s greatest contributions was the maintenance of statistics to show the efficacy of her strategies. The Civil War to the Beginning of the Twentieth Century The Civil War (1860–1865) stimulated the growth of nursing in the United States. Clara Barton, founder of the American Red Cross, cared for soldiers on the battlefields, cleansing their wounds, meeting their basic needs, and comforting them in death. Dorothea Lynde Dix, Mary Ann Ball (Mother Bickerdyke), and Harriet Tubman also influenced nursing during the Civil War (Donahue, 2011). Dix and Bickerdyke organized hospitals and ambulances, appointed nurses, cared for the wounded soldiers,and managed supplies.Tubman was active in the Underground Railroad movement and helped lead more than 300 slaves to freedom (Donahue, 2011). The first professionally educated African-American nurse was Mary Mahoney. She was concerned with relationships between cultures and races. As a nursing leader, she brought forth an awareness of cultural diversity and respect for the individual, regardless of background, race, color, or religion. Isabel Hampton Robb helped found the Nurses’ Associ- ated Alumnae of the United States and Canada in 1896. This organization became the ANA in 1911. She authored many nursing textbooks and was one of the original founders of the American Journal of Nursing (Donahue, 2011). Nursing in hospitals expanded in the late nineteenth century. However, nursing in the community did not increase significantly until 1893, when Lillian Wald and Mary Brewster opened the Henry Street Settlement, which focused on the health needs of poor people who lived in tenements in New York City (Donahue, 2011). Twentieth Century In the early twentieth century, nursing evolved toward devel- oping a scientific, research-based defined body of nursing knowledge and practice. Nurses began to assume expanded and advanced practice roles to meet society’s needs. Mary Adelaide Nutting, the first professor of nursing at Columbia University Teachers College, was instrumental in the affilia- tion of nursing education with universities (Donahue, 2011). In addition, the Goldmark Report concluded that nursing education needed increased financial support. As nursing education developed, nursing practice also expanded, and the Army and Navy Nurse Corps were established. By the 1920s nursing specialization started to develop. The last half of the century saw specialty-nursing organizations such as the American Association of Criti- cal Care Nurses, Association of Operating Room Nurses
- 26. 4 UNIT 1 Concepts in Nursing Workplace Issues Nurses are faced with multiple issues and hazards in the workplace. For example, they are at risk for ergonomic hazards that result in musculoskeletal injuries such as back injury and repetitive motion disorders (ANA, 2016). When looking for a new position, evaluate the workforce protection and safety plan that the hospital or health care organization has in place (Zerwekh and Garneau, 2015). Another issue facing nurses is workplace violence. Work- place violence takes the form of bullying and acts of verbal or nonverbal aggression or harassment from co-workers and sometimes patients and families. Nurses who experience workplace violence often develop anger, fear, anxiety, post- traumatic stress disorder symptoms, guilt, or shame (Huber, 2014). Respect for the dignity and rights of all co-workers is an ethical responsibility for all nurses (NCSBN, 2016). The ANA calls for “zero tolerance” to violence of any kind within the workplace. The ANA recommends evidence- based interventions to prevent violence and to promote the health and safety of nurses (ANA, 2015c). Know the policies of your institution on prevention or response to workplace violence. Nursing Shortage There is an ongoing nursing shortage in the United States, which results from insufficient qualified registered nurses (RNs) to fill vacant positions, the aging population of nurses, and a growing need for health care services (AACN, 2014). An increased number of nurses are retiring; 55% of nurses are aged 50 or older (AACN, 2014; NCSBN, 2016). This shortage affects all nursing care settings, including hospitals, long-term care facilities, administration, and nursing educa- tion (AACN, 2014); it also represents challenges and oppor- tunities for the profession. Many dollars are invested in strategies aimed at increasing student enrollment in nursing programs and recruiting a well-educated, critically thinking, motivated, and dedicated nursing workforce (Benner et al., 2010; AACN, 2014). At the same time hospitals, the largest employer of nurses, seek ways to improve nurse retention. There is a direct link between RN staffing and nursing care with positive patient outcomes including reduced complica- tion rates and a more rapid return of the patient to an optimal functional status (Box 1.1) (Choi and Staggs, 2014; Giuliano et al., 2016). With fewer nurses in the workplace, it is important for you to learn to use your patient contact time efficiently and pro- fessionally. Time management, therapeutic communication, patient education, and compassionate implementation of psychomotor skills are just a few of the essential skills you need. Most important, ensure your patients leave the health care setting with a positive image of nursing and a feeling that they received quality care. Your patient should never feel rushed or that he or she was unimportant. If a certain aspect of patient care requires 15 minutes of contact, it takes the same amount of time to deliver the care in an organized manner as it would in a rushed, harried manner. summarizes reasons for the rise in health care costs and its implications for nursing. Demographic Changes The U.S. Census Bureau (2015) predicts that between 2014 and 2060, there will be a steady rise in the population, although this increase will slow in future decades as fertility rates decline over these years. This change requires expanded health care resources. Add to the population change a steady increase in the percentage of the population of people 65 years of age and older. By 2030 it is estimated that one in five persons will be 65 years of age or older (U.S. Census Bureau, 2015). It is also predicted that by 2044 more than half of the U.S. population will be part of a minority group (U.S. Census Bureau, 2015). To effectively meet all the health care needs of the expanding minority and aging populations, changes in how care is provided are needed, especially in the area of public health. The population is shifting from rural areas to urban centers, and more people are living with chronic and long-term illness (RWJF, 2014). Outpatient settings are expanding, and more people want to receive outpatient and community-based care and remain in their homes or community (see Chapters 3 and 4). Medically Underserved Population Unemployment, underemployment and low-paying jobs, mental illness, poor health care access in rural areas, home- lessness, and health care costs all contribute to increases in the medically underserved population. Caring for this popu- lation is a global issue; the social, political, and economic factors of a country affect both access to care and resources to provide and pay for these services. In the United States, some of the medically underserved population are individu- als who are poor and on Medicaid. Others are part of the working poor (e.g., they cannot afford their own insurance, but they make too much money to qualify for Medicaid and as a result do not receive any health care). Patients who are medically underserved and who have low health literacy are less likely to participate in decision making regarding their care often because they do not understand the medical infor- mation provided (Seo et al., 2016). Today nurses and schools of nursing are developing partnerships to improve health outcomes in underserved communities. Nurses work in these community-based settings providing health promotion and disease prevention. Need for Emergency Preparedness The world is a changing place; the threats of terrorism are continuous. Many health care agencies, schools, and com- munities have educational programs to prepare for nuclear, chemical, or biological attacks and other types of disasters. Nurses play an active role in emergency preparedness ranging from participation in vaccine research, to decontamination in times of biological attack, to triage for mass casualty, to participation in crisis response units. Nurses provide emer- gency preparedness education and prepare for disasters at the local, state, and federal levels (Zerwekh and Garneau, 2015).
- 27. 5 CHAPTER 1 Professional Nursing direct patient care. The LPN/LVN is a nurse who completes a practical nursing program and passes a licensure examina- tion (NCLEX-PN®). The LPN/LVN practices under the supervision of an RN or other licensed person. The respon- sibilities and scope of practice are set by each state board of nursing. An LPN/LVN, or in Canada an RN assistant (RNA), generally receives 1 year of education and clinical preparation in a community college or other agency. Some RN programs allow an LPN to enter the program at an advanced level. Registered Nurse Education As a profession nursing requires that its members possess a significant amount of education. There are various educa- tional routes for becoming a registered nurse (RN). Cur- rently in the United States an individual becomes an RN by earning an associate degree, diploma, or baccalaureate degree program in nursing and by passing the NCLEX-RN® exami- nation. The baccalaureate degree is required as the entry to practice standard for RNs in all provinces of Canada except Quebec (Canadian Nurses Association [CAN], 2016a). Nursing education provides the solid foundation for practice, and it responds to changes in health care created by scientific and technological advances. Advanced Education Some roles for RNs require advanced graduate degrees. A graduate degree provides the advanced clinician with strong skills in nursing science and theory, with an emphasis on the basic sciences and research-based clinical practice related to a specialty. A master’s degree in nursing (e.g., Master of Arts in Nursing [MA], Master of Nursing [MN], or Master of Science in Nursing [MSN]) is for RNs seeking roles such as nurse educator, nurse administrator, clinical nurse leader, nursing informatics specialist, or advanced practice registered nurse (APRN). Some programs require the RN to have a Bachelor of Science in Nursing (BSN) degree before entry; other programs offer entrance to associate degree–prepared nurses who take bachelor’s level courses as they progress through the curriculum toward the master’s degree. Some roles within nursing require doctoral degrees. There are two doctorate degree in nursing options for nurses. The Doctor of Philosophy (PhD) has a focus on research, and the Doctor of Nursing Practice (DNP) has a focus on advanced clinical practice. The health care industry needs nurses pre- pared at the doctorate level with advanced academic and clinical preparation to educate nursing students and partici- pate as members of the interdisciplinary health care team to provide evidence-based, competent, safe patient care (IOM, 2010). Nurses with doctorates advance the profession by pro- moting evidence-based practice, developing practice guide- lines, conducting and disseminating research, developing and testing theory, educating future nurses, and influencing public policy and health care planning. Continuing and In-Service Education Continuing education programs are one way to promote and maintain current nursing skills, gain new knowledge PROFESSIONALISM Nursing is a profession. A person who acts professionally is conscientious in actions, knowledgeable in the subject, and responsible to self and others. This means that as a nurse you administer patient-centered care in a safe, conscientious, and knowledgeable manner. Professions possess the following characteristics: • An extended education of members and a basic liberal education foundation • A theoretical body of knowledge leading to defined skills, abilities, and norms • Provision of a specific service • Autonomy in decision making and practice • A code of ethics for practice Nursing shares each of these characteristics, offering an opportunityforthegrowthandenrichmentof allitsmembers. Licensed Practical Nurse/Licensed Vocational Nurse Education A licensed practical nurse (LPN) or licensed vocational nurse (LVN) is educated in basic nursing techniques and PICO Question: Are patient outcomes improved in hos- pitals with adequate nursing staffing versus hospitals with lower nursing staffing? SUMMARY OF EVIDENCE There is a growing body of research that shows that nurse staffing does impact patient outcomes, patient survival, and the occurrence of adverse events. A secondary data analysis from 661 hospitals showed that there was a significantly lower 30-day readmission rate for patients with heart failure in hospitals that had high nurse staffing, thus reducing health care costs (Giuliano et al., 2016). Higher nurse staffing was also found to significantly increase the survival of patients in an intensive care unit (West et al., 2014). Patients experienc- ing an in-hospital cardiac arrest were more likely to survive when there was a decreased patient-to-nurse ratio (McHugh et al., 2016). Cho et al. (2016) found that larger numbers of patients assigned to a nurse increased the occurrence of medication errors, pressure injury formation, and falls with injuries. Studies demonstrating the positive impact that nurse-to-patient ratios have on outcomes provide nursing administrators with evidence to support hiring of qualified professional nurses. APPLICATION TO NURSING PRACTICE • Consider the nurse-to-patient ratio when looking at a hos- pital or unit for employment. • Adequate nursing levels help to improve the nursing work environment (Cho et al., 2016). • Improved working conditions increase the likelihood of patient survival in emergency events (McHugh et al., 2016). • Continuing research needs to be conducted to study the economic impact of nurse staffing and improved patient outcomes (Giuliano et al., 2016). BOX 1.1 EVIDENCE-BASED PRACTICE
- 28. 6 UNIT 1 Concepts in Nursing education, and the support of an organization that values the independent role of the nurse. With increased autonomy comes greater responsibility and accountability for the per- formance of nursing care activities. Accountability means that you are professionally and legally responsible for the type and quality of nursing care provided. To be autono- mous and accountable carries the responsibility to keep current and competent in nursing and scientific knowledge and skills. Code of Ethics Nursing’s code of ethics defines the principles that nurses use to provide patient-centered care (see Chapter 6). In addition, nurses incorporate their own values and ethics into practice. The ANA’s Code of Ethics for Nurses: With Interpre- tive Statements (2015b) provides a guide for carrying out nursing responsibilities to ensure high-quality nursing care and provide for the ethical obligations of the profession. Developing Professionalism in Your Career It is important that you work to develop professionalism early in your nursing career. Professionalism in appearance and behaviors is critical to earning recognition and respect as a nurse (Splendore et al., 2016). The use of social media is prevalent with both nursing students and professional nurses (Mamocha et al., 2015). You need to be very aware of your use of social media and practice e-professionalism (Westrick, 2016). Social media has positive uses for provid- ing patient education, providing communication, and fos- tering professional connections (NCSBN, 2011). However, inappropriate use of social media violates legal, ethical, and professional standards. Research has shown that there are an increasing number of incidents of nursing students and practicing nurses posting unprofessional content, such as patients’ personal health information (PHI), on social media sites (Westrick, 2016). Cyberbullying was also found to have occurred against both peers and faculty (Mamocha et al., 2015). As a nurse you must be aware of social media ethical and professional standards that you need to follow. Be aware of both personal and professional information that you share on social media sites. You will violate state and federal laws if you share patient health information on social media sites (NCSBN, 2011). Check your agency or school policy on use of social media to ensure that you are acting profes- sionally when using social media (Brown, 2016). To protect yourself and your patients, follow the guidelines on use of social media established by the ANA and National Council of State Boards of Nursing (ANA, 2011; NCSBN, 2011; Westrick, 2016). It is important that you display professionalism when applying for nursing positions. Professional communication dictates that you send a cover letter when submitting your resume, a thank-you letter for the interview opportunity, and a resignation letter if you are leaving your position (Yoder- Wise, 2014). The professional letter and resume that you submit is often the first impression you make on the indi- vidual who is hiring nurses. Make sure that your letters are about the latest research and practice developments, gain certification credits to specialize in a specific practice area, meet requirements for continuing licensure as a nurse, and obtain new skills and techniques reflecting the changes in the health care delivery system. Continuing education involves formal, organized educational programs offered by universities, hospitals, state nurses associations, profes- sional nursing organizations, and educational and health care institutions. Examples include a program on caring for older adults with dementia offered by a university or a program on safe medication practices offered by a hospital. Often these programs provide attendees with some type of continuing education credit. In-service education programs contain instruction or training provided by a health care agency or institution designed to increase the knowledge, skills, and competencies of nurses and other health care professionals employed by the institution. Often in-service programs focus on new tech- nologies or fulfill required competencies of the organization. For example, a hospital offers an in-service program on safe principles for administering chemotherapy or a program on cultural sensitivity. Theory Professional nursing practice and knowledge have developed in part through nursing theories (global views that help to describe, predict, or prescribe activities for the practice of nursing). Theoretical models provide frameworks for how nurses practice. Some nursing school curricula integrate a theoretical model. Some nursing organizations adopt a nursing theory as the foundation for their standards of nursing care. Examples of theories used in education and practice are Orem’s self-care deficit theory, Benner’s primacy of caring, and Watson’s Theory of Human Caring. The ongoing development of nursing theory or nursing science involves generating knowledge to advance and support nursing practice and health care (Alligood, 2014). Service Nursing is a service profession and a vital and indispensable part of the health care delivery system. Nurses in practice maintain a consumer-based and service-based focus. Patients are more knowledgeable about their health care problems, options, and rights. As a nurse you work with patients and families individualizing care while incorporating their prefer- ences and expectations. Show respect by providing care on time, displaying a caring attitude, and considering patients’ cultural and social differences. Collaborate with necessary health care providers to ensure continuation of care from one setting to the next. Autonomy and Accountability Autonomy is essential to professional nursing and involves the initiation of independent nursing interventions without medical orders. Autonomy means that a person is reason- ably independent and self-governing in decision making and practice. You reach autonomy through experience, advanced
- 29. 7 CHAPTER 1 Professional Nursing individual State Boards of Nursing to obtain a nursing license. Regardless of educational preparation, the exami- nation for RN licensure is exactly the same in every state in the United States to provide a standardized minimum knowledge base for nurses. As of January 2015, new gradu- ates of Canada’s 10 provinces/territories must also pass the NCLEX-RN® to become an RN (CNA, 2016b). Whether nurses are able to practice in a state or province other than their own depends on the agreement between the states or provinces involved. Certification. Beyond the NCLEX-RN®, some nurses work toward certification in a specific area of nursing prac- tice. Minimum practice requirements are set based on the certification. National nursing organizations such as the American Nurses Credentialing Center (ANCC) have many types of certification to enhance your career such as certifica- tion in medical-surgical or geriatric nursing. After passing the initial examination, you maintain your certification by ongoing continuing education and clinical or administrative practice. STANDARDS OF NURSING PRACTICE Nursing is a helping, independent profession that provides services that contribute to the health of people. Three essen- tial components of professional nursing are care, cure, and coordination. The care aspect is more than “to take care of”; it is also “caring about.” Caring is relational and requires you as a nurse to understand a patient’s needs so that you can individualize nursing therapies (see Chapter 20). When you promote health and healing, you are practicing the cure aspect of professional nursing. To cure is to help patients understand their health problems, manage their symptoms and cope. The cure aspect involves the administration of treatments and the use of clinical nursing judgment in determining, on the basis of patient outcomes, whether the plan of care is effective. Coordination of care involves organizing and timing medical and other professional and technical services to meet the holistic needs of a patient. Often a patient requires many services simultaneously for care to be effective. A professional nurse also supervises, teaches, and directs all individuals involved in nursing care. As an independent profession, nursing sets its own stan- dards for practice. These standards define competent nursing care and how nurses exercise the care, cure, and coordination aspects of nursing. Clinical, academic, and administrative nurse experts develop standards of nursing practice. As an example, the ANA has published Nursing: Scope and Stan- dards of Practice (2015a).Within this document are Standards of Professional Performance and Standards of Practice for professional nurses (see http://www.nursingworld.org/ scopeandstandardsofpractice). In the practice setting it is important to have objective guidelines for providing and evaluating nursing care. Stan- dards of nursing care are developed and established on the basis of strong scientific research and the work of clinical professional in appearance, using appropriate paper and good grammar with no misspellings. Your resume should be typed, printed on high-quality paper, accurate, error-free, and grammatically correct (Yoder-Wise, 2014). For your interview, dress in professional clothing. Do not wear scrubs. Be prepared for the interview and be prepared to answer questions that are related to “how you handled a challenging situation” or discussing your strengths and opportunities for improvement. Other questions may focus on how your education has prepared you for the position for which you are interviewing. Turn off and put away all your electronic devices so that you are not distracted by them during the interview. Avoid eating, drinking, and chewing gum during the interview. The first impression that you make on patients is often related to your appearance. Your uniform is a form of non- verbal communication with patients (Splendore et al., 2016). Your uniform should be clean, be odor-free, and fit appropri- ately conveying a professional appearance. Make sure that you follow your agency dress code so that you are professional in your appearance when providing care to patients. Nursing uniforms have a positive impact on the patient experience (Splendore et al., 2016). NURSING PRACTICE You will have an opportunity to practice in a variety of set- tings, in many roles within those settings, and with caregivers in other related health professions. State and provincial Nurse Practice Acts (NPAs) establish specific legal regulations for practice. The ANA is concerned with nursing practice, public recognition of the significance of nursing practice to health care, and implications for nursing practice regarding trends in health care. The ANA definition of nursing illustrates the consistent need for nurses to promote the well-being of their patients individually or in groups and communities (Fowler, 2015a). State and provincial NPAs establish specific legal regulations for nursing practice. Professional organizations such as the ANA establish professional standards for practice. Nurse Practice Acts In the United States each State Board of Nursing oversees its NPA. The NPA regulates the scope of nursing practice for the state and protects public health, safety, and welfare. This includes protecting the public from unqualified and unsafe nurses. Although each state has its own NPA that defines the scope of nursing practice, most NPAs are similar. The definition of nursing practice published by the ANA is repre- sentative of the scope of nursing practice as defined in most states. During the last decade, many states have revised their NPAs to reflect the growing autonomy of nursing, minimum education requirements, certification requirements, and the expanded roles and scope of practice of APRNs. Licensure and Certification Licensure. In the United States RN candidates must pass the NCLEX-RN® examination administered by the
- 30. 8 UNIT 1 Concepts in Nursing nurse experts. A standard of care describes the common level of professional nursing care to achieve quality nursing practice. An organization sometimes adopts a general set of standards for nursing care such as organizational proto- cols, policies, or procedures. For example, an organization has a written nasogastric tube protocol based on research findings. This protocol spells out the expected nursing care for patients with nasogastric tubes in that organiza- tion. Individual nursing units or work groups also establish standards of care to address the unique needs of patients in their care. For example, an oncology nursing unit devel- ops standards of care for pain management and palliative care for patients with cancer. More important, standards of care establish the guidelines for nursing excellence within an organization. RESPONSIBILITIES AND ROLES OF THE NURSE As a nurse you are responsible for obtaining and maintain- ing specific knowledge and skills for a variety of profes- sional roles and responsibilities. Nurses provide care and comfort for patients in all health care settings. Their concern for meeting patients’ needs remains the same whether care focuses on health promotion and illness prevention, disease and symptom management, family support, or end-of-life care. Caregiver As caregiver you help patients maintain and regain health, manage disease and symptoms, and attain a maximal level function and independence through the healing process. You provide evidence-based nursing care to promote healing through both physical and interpersonal skills. Healing involves more than achieving improved physical well- being. You need to meet all health care needs of a patient by providing measures that restore the patient’s emo- tional, spiritual, and social well-being. As a caregiver you help the patient and family set goals and assist them with meeting these goals with minimal financial cost, time, and energy. Most nurses provide direct patient care in an acute care setting, whereas some pursue a specific area of specialty prac- tice such as pediatrics, critical care, or emergency care. Many specialty care areas require some experience as a medical- surgical nurse and certification in advanced cardiac life support and critical care, emergency nursing, or trauma nursing. As health care returns to the home care setting, there are increased opportunities for you to provide direct care in a patient’s home or community. Use the nursing process and critical thinking skills to provide care that is restorative, curative, and evidence-based. Educate your patients and families to promote health maintenance and self-care. In col- laboration with other health care team members, focus your care on returning patients to their home at an optimal functional status. Lucas participates in a team meeting to help plan care for Mr. Thompson. • To be an effective team member, which competencies should Lucas use to promote teamwork and collab- oration during the planning process? Answers to QSEN Activities can be found on the Evolve website. QSEN ACTIVITY Teamwork and Collaboration Copyright © sturti/ Getty Images. Advocate As a patient advocate you protect your patient’s human and legal rights and provide assistance in asserting these rights if the need arises. As an advocate you act on behalf of your patient, securing and standing up for your patient’s health care rights (Kowalski, 2016). For example, you provide infor- mation to help a patient decide whether or not to accept a treatment, or you find an interpreter to help family caregivers communicate their concerns. You sometimes need to defend patients’ rights in a general way by speaking out against poli- cies or actions that put patients in danger or conflict with their rights. Educator As an educator you explain concepts and facts about health, describe the reason for routine care activities, demonstrate procedures such as self-care activities, reinforce learning or patient behavior, and evaluate patients’ progress in learning. Sometimes patient teaching is unplanned and informal (see Chapter 12). For example, during a casual conversation you respond to questions about the reason for an intravenous infusion, a health issue such as smoking cessation, or neces- sary lifestyle changes. Other teaching activities are planned and more formal such as when you teach your patient to self- administer insulin injections. Always use teaching methods that match your patient’s capabilities and needs, and incor- porate other resources such as family members or caregivers in teaching plans (see Chapter 25). Communicator Your effectiveness as a communicator is central to the nurse- patient relationship. It allows you to know your patients, including their strengths and weaknesses and their needs; and when possible, to know the family’s concerns and needs. Communication is essential for all nursing roles and activi- ties. You routinely communicate with patients and families, other nurses and health care professionals, resource persons, and the community. Without clear communication it is impossible to give comfort and emotional support, give care effectively, make decisions with patients and families, protect patients from threats to well-being, coordinate and manage patient care, assist patients in rehabilitation, or provide patient education. The quality of communication is
- 31. 9 CHAPTER 1 Professional Nursing area of practice (AACN, 2006, 2011). In 2008, the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee developed the Consensus Model for APRN Regulation: Licensure, Accredi- tation, Certification and Education. The Consensus model identified that the title of APRN is for nurses with advanced graduate–level knowledge prepared in one of four roles: clini- cal nurse specialist (CNS), nurse practitioner (NP), certified nurse-midwife (CNM), and certified registered nurse anes- thetist (CRNA). The educational preparation for the four roles is in at least one of the following six populations: adult- gerontology, pediatrics, neonatology, women’s health/gender related, family/individual across life span, and psychiatric mental health. APRNs function within their area of practice to plan or improve the quality of nursing care for patients and their families. Clinical Nurse Specialist. The clinical nurse specialist (CNS) is an APRN who is an expert clinician in a specialized area of practice. The specialty may be identified by a popula- tion (e.g., geriatrics), setting (e.g., critical care), disease spe- cialty (e.g., diabetes), type of care (e.g., rehabilitation), or type of problem (e.g., pain) (NACNS, 2016). The CNS prac- tices in all health care settings. Nurse Practitioner. The nurse practitioner (NP) is an APRN who provides health care to a group of patients,usually in an outpatient, ambulatory care, or community-based setting. The major NP categories are acute care, adult, family, pediatric, women’s, psychiatric mental health, and geriatric. The NP provides comprehensive care, directly managing the medical care of patients who are healthy or have chronic conditions, and establishes a collaborative provider-patient relationship, working with a specific group of patients or with patients of all ages and health care needs. Certified Nurse-Midwife. The certified nurse-midwife (CNM) is an APRN who is educated in midwifery and is certified by the American College of Nurse-Midwives. The practice of nurse-midwifery involves providing independent care for women during normal pregnancy, labor, and delivery and care for the newborn. It includes providing some gyne- cological services such as routine Papanicolaou (Pap) tests, family planning, and treatment for minor vaginal infections. Certified Registered Nurse Anesthetist. A certified regis- tered nurse anesthetist (CRNA) is an APRN with advanced education earned in a nurse anesthesia accredited program. Nurse anesthetists provide surgical anesthesia under the guidance and supervision of an anesthesiologist, who is a physician with advanced knowledge of surgical anesthesia. Nurse Educator. A nurse educator works primarily in schools or programs of nursing, staff development depart- ments of health care agencies, and patient education depart- ments. They usually have a specific clinical, administrative, or research specialty and advanced clinical and educational experience. A faculty member in a school of nursing is responsible for teaching current nursing practice, trends, theory, and necessary skills in laboratories and clinical set- tings to educate students to become professional nurses. a critical factor in meeting the needs of individuals, families, and communities (see Chapter 11). Leader Leaders are found in all areas of nursing and at all levels, functioning in both formal and informal settings. As a leader, you will work with others to create a vision and then make decisions and take action to achieve this vision.You will assess the situation, identify strategies using the best evidence, and guide others toward the vision (Yoder-Wise, 2014). Your behaviors and attitudes will impact those that you lead. As a leader, you must inspire others. A good leader should have the skills of self-awareness, self-management, social aware- ness, and relationship management (Huber, 2014). Effective leadership requires you to grow through ongoing personal development and good communication skills. One strategy to develop your leadership skills is to select a mentor who models effective leadership. Your mentor can be your role model, coach, and teacher (Yoder-Wise, 2014). Manager Today’s health care environment is fast paced and complex. Nurse managers need to establish an environment for col- laborative patient-centered care to provide safe, quality care with positive patient outcomes. A manager coordinates the activities of members of the nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency. The manager uses appropriate leadership styles to create a nursing environment for the patients and staff that reflects the mission and values of the health care organization (see Chapter 13). Career Development Innovations in health care, expanding health care systems and practice settings, and the increasing needs of patients have created new nursing roles. Today most nurses practice in hospital settings, community-based care, ambulatory care, and nursing homes or extended care settings. Nursing allows you to commit to lifelong learning and career development to provide patients the state-of-the-art care they need. Career roles are specific employment posi- tions or paths. Because of increasing educational opportuni- ties for nurses, the growth of nursing as a profession, and a greater concern for job enrichment, the nursing profession offers expanded roles and different kinds of career opportu- nities. Your career path is limitless. You will probably switch career roles more than once. Take advantage of the different clinical practice and professional opportunities. These career opportunities include APRNs, nurse educators, nurse admin- istrators, and nurse researchers. Advanced Practice Registered Nurse. The advanced practice registered nurse (APRN) is the most independently functioning nurse. An APRN has a master’s degree or Doctor of Nursing Practice (DNP) degree in nursing; advanced education in pathophysiology, pharmacology, and physical assessment; and certification and expertise in a specialized
- 32. 10 UNIT 1 Concepts in Nursing nurse researcher often works in an academic setting, hospital, or independent professional or community service agency. The preferred educational requirement is a doctoral degree, with at least a master’s degree in nursing. PROFESSIONAL NURSING ORGANIZATIONS A professional organization deals with issues of concern to individuals practicing in the profession. In North America twomajorprofessionalnursingorganizationsaretheNational League for Nursing (NLN) and the ANA. The NLN advances excellence in nursing education to prepare nurses to meet the needs of a diverse population in a changing health care environment. The purposes of the ANA are to improve standards of health and the availability of health care, foster high standards for nursing, and promote the professional development and general and economic welfare of nurses. The ANA is part of the International Council of Nurses (ICN). The objectives of the ICN parallel those of the ANA: promoting national associations of nurses, improving standards of nursing prac- tice, seeking a higher status for nurses, and providing an international power base for nurses. The ANA is active in political, professional, and financial issues affecting health care and the nursing profession. It is a strong lobbyist in professional practice issues. Nursing students may take part in organizations such as the National Student Nurses’ Association (NSNA) in the United States and the Canadian Student Nurses’ Association (CSNA) in Canada. These organizations consider issues of importance to nursing students such as career development and preparation for licensing. The NSNA often cooperates in activities and programs with the professional organizations. Some professional organizations focus on specific areas such as critical care, nursing administration, nursing research, or nurse-midwifery. These organizations seek to improve the standards of practice, expand nursing roles, and foster the welfare of nurses within the specialty areas. In addition, pro- fessional organizations present educational programs and publish journals. TRENDS IN NURSING Nursing is a dynamic profession that grows and evolves as society and lifestyles change, as health care priorities and technologies change, and as nurses themselves change. The current philosophies and definitions of nursing have a holis- tic focus, which addresses the needs of the whole person in all dimensions, in health and illness, and in interaction with the family and community. Additionally, there is a definitive focus on patient safety in all care settings. Quality and Safety Education for Nurses The Robert Wood Johnson Foundation sponsored the Quality and Safety Education for Nurses (QSEN) initiative to respond to reports about safety and quality patient care by the Institute of Medicine (IOM) (QSEN Institute, 2014a). Nurse educators in educational programs of nursing usually have graduate degrees in nursing and additional education such as a doctorate or an advanced degree in nursing, education, or administration such as a Master of Business Administration (MBA). Nurse educators in staff development departments of health care institutions provide educational programs for nurses within their institutions. These programs include orientation of new personnel, critical care nursing courses, assisting with clinical skill competency, safety training, instruction about new equipment or procedures, and partici- pation in developing nursing policies and procedures. The primary focus of the nurse educator in a patient edu- cation department of an agency is to teach patients and their families how to self-manage their illness or disability. These nurse educators are usually specialized and certified such as a Certified Diabetes Educator (CDE) or an ostomy care nurse and see only a specific population of patients. Nurse Administrator. A nurse administrator manages patient care and the delivery of specific nursing services within a health care agency. Nursing administration often begins with positions such as the assistant nurse manager. Experience and additional education sometimes lead to a middle-management position such as nurse manager of a specific patient care area or house supervisor or an upper- management position such as assistant or associate director or director of nursing services. Nurse manager positions usually require at least a bacca- laureate degree in nursing, and director and nurse executive positions generally require a master’s degree. Chief nurse executives and vice president positions in large health care organizations often require preparation at the doctoral level. Nurse administrators frequently have advanced degrees such as Master of Nursing Administration, MBA, Master of Hos- pitalAdministration (MHA),Master of Public Health (MPH), or Master of Health Service Administration. In today’s health care organizations directors may have responsibility for more than nursing units or manage a par- ticular service or product line such as medicine or cardiology. Management of a service line often includes directing sup- portive functions and the health care personnel within areas such as medicine clinics, diagnostic departments, or outpa- tient care settings. Vice presidents of nursing or chief nurse executives often have responsibilities for all clinical functions within a hospi- tal. This may include all ancillary personnel who provide and support patient care services. The nurse administrator needs to be skilled in business and management and understand all aspects of nursing and patient care. Functions of admin- istrators include budgeting, staffing, strategic planning of programs and services, employee evaluation, and employee development. Nurse Researcher. The nurse researcher investigates problems to improve nursing care and further define and expand the scope of nursing practice (see Chapter 7). The
- 33. 11 CHAPTER 1 Professional Nursing method to document and manage patient health care infor- mation (see Chapter 10). Computerized physician/provider order entry (CPOE) is a critical patient safety initiative (Houston, 2014). Additionally, the availability and use of telehealth and telemedicine functions to provide health care are increasing (NCSBN, 2016). Genomic information com- bined with technology can improve health outcomes, quality, and safety and reduce health care costs (McCormick and Calzone, 2016). Technological innovations help family care- givers monitor and manage home environments of older adults, enable older adults to stay in their homes but stay connected to their support systems, and help with decision support and care coordination (Andruszkiewicz and Fike, 2015–2016). Younger nurses entering the workforce today have a high aptitude for technology. When surveyed, these nurses indicated that they would like to receive their health care through mobile devices and telehealth (NCSBN, 2016). Genomics Genetics is the study of inheritance, or the way traits are passed down from one generation to another. Genes carry the instructions for making proteins, which direct the activi- ties of cells and functions of the body that influence traits such as hair and eye color. Genomics is the study of all the genes in a person and interactions of these genes with one another and with that person’s environment (McCormick and Calzone, 2016). Using genomic information allows QSEN addresses the challenge to prepare nurses with the competencies needed to continuously improve the quality of care in their work environments (Table 1.1). The QSEN initiative encompasses the competencies of patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (QSEN Insti- tute, 2014a). For each competency there are targeted knowl- edge, skills, and attitudes (KSAs). Different KSAs apply for nursing students in prelicensure as well as graduate nursing programs (QSEN Institute, 2014b; Sherwood and Zomorodi, 2014). As you gain experience in clinical practice, you encounter situations in which your education helps you to make a dif- ference in improving patient care. Whether that difference in care is to provide evidence for implementing care at the bedside, identify a safety issue, or study patient data to iden- tify trends in outcomes, each of these situations requires com- petence in patient-centered care, safety, or informatics. Emerging Technologies As a nurse you will be affected by emerging technologies found in today’s health care environment. These technologies have the potential to change nursing practice. New technolo- gies provide more accurate, noninvasive assessment tools; help you to implement evidence-based practices; collect and trend patient outcome data; and use clinical decision support systems. The electronic health record (EHR) is an efficient TABLE 1.1 QUALITY AND SAFETY EDUCATION FOR NURSES COMPETENCY DEFINITION WITH EXAMPLES Patient-centered care Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs. Examples: Involve family and friends in care. Elicit patient’s values and preferences. Provide care with respect for diversity of the human experience. Teamwork and collaboration Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care. Examples: Recognize the contributions of other health team members and patient’s family members. Discuss effective strategies for communicating and resolving conflict. Participate in designing methods to support effective teamwork. Evidence-based practice Integrate best current evidence with clinical expertise and patient and/or family preferences and values for delivery of optimal health care. Examples: Demonstrate knowledge of basic scientific methods. Appreciate strengths and weaknesses of scientific bases for practice. Appreciate the importance of regularly reading relevant journals. Quality improvement Use data to monitor the outcomes of care processes, and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. Examples: Use tools such as flow charts and diagrams to make process of care explicit. Appreciate how unwanted variation in outcomes affects care. Identify gaps between local and best practices. Safety Minimize risk of harm to patients and providers through both system effectiveness and individual performance. Examples: Examine human factors, basic safety design principles, and commonly used unsafe practices. Value own role in preventing errors. Informatics Use information and technology to communicate, manage knowledge, mitigate error, and support decision making. Examples: Navigate an electronic health record. Protect confidentiality of protected health information in electronic health records. Adapted from QSEN Institute: Pre-licensure KSAs, 2014, http://qsen.org/competencies/pre-licensure-ksas/.
- 34. 12 UNIT 1 Concepts in Nursing health care providers to determine how genomic changes contribute to patient conditions and influence treatment decisions such as assessment and symptom management and titration of medications based on a patient’s response (McCormick and Calzone, 2016). For example, when a family member has colon cancer before the age of 50, it is likely that other family members are at risk for developing this cancer. Knowing this information is important for family members who may need a colonoscopy before age 50 and repeat colo- noscopies more often than patients who are not at risk. In this case nurses play an essential role in identifying a patient’s risk factors through assessment and counseling patients about what this genomic finding means to them personally and to their family. Nurses need to increase their knowledge of genomics in order to provide effective, individualized genetic and genomic information and resources to their patients (Sharoff, 2016). Public Perception of Nursing Nursing is a crucial health care profession. As frontline health care providers, nurses practice in all health care set- tings and constitute the largest number of health care pro- fessionals. They provide skilled, specialized, knowledgeable care; improve the health status of the public; and ensure safe, effective quality care (ANA, 2015b). The Gallup survey continues to find that survey participants ranked nurses highest among professionals for honesty and ethics (Advisory Board, 2015). Consumers of health care are more informed than ever, and with the Internet consumers have access to more health care and treatment information. This information affects the perception the public has of nursing. For example, the media frequently highlights incidents of preventable medical errors such as medication and surgical errors. Publications such as To Err Is Human (IOM, 2000) describe strategies for govern- ment, health care providers, industry, and consumers to reducepreventablemedicalerrors.Whenyoucareforpatients, realize how your approach to care influences public opinion. Always act in a competent professional manner. Effect of Nursing on Politics and Health Policy Involvement of nurses in politics is receiving greater empha- sis in nursing curricula, professional organizations, and health care settings. Professional nursing organizations at both the national and the state level employ lobbyists to urge U.S. Congress and state legislatures to improve the quality of health care (Mason et al., 2016). You can influence policy decisions at all governmental levels. One way to get involved is by participating in local and national efforts (Mason et al., 2016). This involvement is critical in exerting nurses’ influence early in the political process. The future is bright when nurses become serious students of social needs, activists in influencing policy to meet those needs, and generous contributors of time and money to nursing organizations and candidates who support efforts to improve access to and quality of health care (Mason et al., 2016). K E Y P O I N T S • A profession possesses the characteristics of extended edu- cation, theory, service, autonomy, and a code of ethics. • The essential components of professional nursing are care, cure, and coordination. • During your education begin to develop professionalism through an ongoing understanding of what denotes appropriate appearance and behaviors, ethical practices (including those associated with social media), and stan- dards of practice. • Nursing standards of care offer evidence-based guidelines for nurses to provide and evaluate care. • State or provincial boards of nursing regulate the scope of nursing practice and protect the public health, safety, and welfare with its established Nurse Practice Act. • Nursing responds to the health care needs of society, which are influenced by economic, social, and cultural variables of a specific era. • Changes in society such as increased technology, new demographic patterns, consumerism, health promotion, and the women’s and human rights movements lead to changes in nursing. • Nursing definitions reflect the practice of nursing by iden- tifying the domain of nursing practice and guiding research, practice, and education. R E F L E C T I V E L E A R N I N G • Reviewing the history of nursing, discuss a key influence or event that you feel impacted the advancement of the nursing profession. • Consider your clinical day and discuss the nursing roles you functioned in today. Was there anything that you would do differently or improve? • Thinking back on your clinical day, which QSEN compe- tency knowledge, skills, or attitudes did you use while providing care today? R E V I E W Q U E S T I O N S 1. You are preparing a presentation for your nursing course on the topic of professional standards of care.Which state- ments best describe professional standards of care? (Select all that apply.) 1. Describe a competent level of behavior in the profes- sional role 2. Protect the patient’s confidentiality 3. Are based on scientific research 4. Provide the foundation for decision making for nurses 5. Define the principles of right and wrong to provide patient care
- 35. 13 CHAPTER 1 Professional Nursing 4. The nurse is preparing a presentation on the nursing pro- fession and factors that are creating impact. Which are key factors impacting professional nursing today that should be included in the presentation? (Select all that apply.) 1. Increasing prevalence of workplace violence 2. Increased need for knowledge on emergency preparedness 3. The rising rate of the medically underserved population 4. Shift of the population from urban settings to rural areas 5. Increased number of nurses reaching retirement age 5. A nurse has responsibility for the nursing budget, develops strategic programs, and oversees staffing for all clinical departments in a hospital. The nurse is practicing in which nursing role? 1. Nurse manager 2. Nurse administrator 3. Nurse educator 4. Nurse researcher Additional Review Questions, as well as rationales for all Review Questions, can be found on the Evolve website. 2. The nurse is providing a patient and caregiver information about the low-sodium diet ordered by the health care pro- vider. The nurse uses teach-back to determine the patient’s understanding of the diet.Which professional nursing role is demonstrated by the nurse? 1. Manager 2. Educator 3. Researcher 4. Caregiver 3. The nurse participates in a team care conference for a patient. The nurse listens to the registered dietitian and physical and occupational therapists detail the plan for the patient. The nurse then describes the patient’s concerns about walking to the group. This is an example of which QSEN competency? 1. Patient-centered care 2. Safety 3. Teamwork and collaboration 4. Evidence-based practice 1. 1, 3, 4; 2. 2; 3. 3; 4. 1, 2, 3, 5; 5. 2. REFERENCES Advisory Board: Why nurses again top Gallup’s list of “most trusted” professionals, 2015. The Advisory Board Company, https://www.advisory.com/ daily-briefing/2015/01/05/why-nurses -again-top-gallups-list-of-most -trusted-professionals. Alligood MR: Nursing theory: utilization and application, ed 5, St Louis, 2014, Elsevier. American Association of Colleges of Nursing (AACN): The essentials of doctoral education for advanced nursing practice, Washington, DC, 2006, The Association. American Association of Colleges of Nursing (AACN): The essentials of master’s education for advanced practice nursing, Washington, DC, 2011, The Association. American Association of Colleges of Nursing (AACN): AACN nursing shortage fact sheet, 2014. http:// www.aacn.nche.edu/media-relations/ NrsgShortageFS.pdf. American Association of Colleges of Nursing (AACN): ELNEC fact sheet, 2016. http://www.aacn.nche.edu/elnec/ about/fact-sheet. American Nurses Association (ANA): Social networking principles toolkit, 2011. http://nursingworld.org/ FunctionalMenuCategories/AboutANA/ Social-Media/Social-Networking -Principles-Toolkit. American Nurses Association (ANA): Nursing: scope and standards of practice, ed 3, Silver Spring, MD, 2015a, The Association. American Nurses Association (ANA): Code of ethics for nurses with interpretive statements, Silver Spring, MD, 2015b, The Association. American Nurses Association (ANA): Incivility, bullying, and workplace violence. ANA Position Statement, 2015c. http://www.nursingworld.org. American Nurses Association (ANA): Handle with care fact sheet, 2016. http://www.nursingworld.org/ MainMenuCategories/ANAMarketplace/ Factsheets-and-Toolkits/FactSheet.html. Andruszkiewicz G, Fike K: Emerging technology trends and products: how tech innovations are easing the burden of family caregiving, Generations 39(4):64, 2015–2016. APRN Consensus Work Group, the National Council of State Boards of Nursing APRN Advisory Committee: Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education, 2008. http://www .nursecredentialing.org/Certification/ APRNCorner/APRN-FAQ. Benner P: From novice to expert: excellence and power in clinical nursing practice, Menlo Park, CA, 1984, Addison-Wesley. Benner P, Tanner CA, et al: The social fabric or nursing knowledge, Am J Nurs 97(7):16, 1997. Benner P, et al: Educating nurses: a call for radical transformation, Stanford, CA, 2010, Carnegie Foundation for the Advancement of Teaching. Brown DW: Social media policies for employers and employees: regulatory and statutory considerations, J Nurs Reg 6(4):45, 2016. Canadian Nurses Association (CNA): Becoming an RN, 2016a. https://
- 36. 14 UNIT 1 Concepts in Nursing www.cna-aiic.ca/en/becoming-an-rn/ education. Canadian Nurses Association (CNA): RN exam, 2016b. https://www.cna-aiic.ca/en/ becoming-an-rn/rn-exam. Cho E, et al: The relationships of nurse staffing level and work environment with patient adverse events, J Nurs Scholarsh 48(1):74, 2016. Choi J, Staggs VS: Comparability of nurse staffing measures in examining the relationship between RN staffing and unit-acquired pressure ulcers: a unit-level descriptive, correlational study, Int J Nurs Stud 51:1354, 2014. Donahue MP: Nursing: the finest art—an illustrated history, ed 3, St Louis, 2011, Mosby. Fowler DM: Guide to nursing’s social policy statement: understanding the profession from social contract to social covenant, Silver Spring, MD, 2015a, American Nurses Publishing. Fowler DM: Guide to the Code of Ethics for nurses with interpretive statements: development, interpretation and application, Silver Spring, MD, 2015b, The Association. Giuliano KK, et al: The relationship between nurse staffing and 30-day readmission for adults with heart failure, J Nurs Admin 46(1):25, 2016. Houston C: Technology in the health care workplace: benefits, limitations, and challenges. In Houston CJ, editor: Professional issues in nursing: challenges and opportunities, ed 3, Philadelphia, 2014, Lippincott Williams Wilkins. Huber DL: Leadership nursing care management, ed 5, St Louis, 2014, Elsevier. Institute of Medicine (IOM): To err is human, Washington, DC, 2000, The Institute. Institute of Medicine (IOM): The future of nursing: leading change, advancing health, Washington, DC, 2010, National Academies Press. International Council of Nurses (ICN): ICN definition of nursing, 2016. http://www.icn.ch/who-we-are/ icn-definition-of-nursing/. Kowalski K: Professional behavior in nursing, J Contin Educ Nurs 47(4):158, 2016. Mamocha S, et al: Unprofessional content posted online among nursing students, Nurse Educ 40(3):119, 2015. Mason DJ, et al: Policy politics in nursing and health care, ed 7, St Louis, 2016, Elsevier. McCormick KA, Calzone KA: The impact of genomics on health outcomes, quality, and safety, Nurs Manage 47(4):23, 2016. McHugh MD, et al: Better nurse staffing and nurse work environments associated with increased survival of in-hospital cardiac arrest patients, Med Care 54(1):74, 2016. National Association of Clinical Nurse Specialists (NACNS): CNS FAQs, 2016, http://nacns.org/html/cns-faqs.php. National Council of State Boards of Nursing (NCSBN): A nurse’s guide to the use of social media, Chicago, IL, 2011, NCSBN. National Council of State Boards of Nursing (NCSBN): A changing environment: 2016 NCSBN environmental scan, J Nurs Reg 6(4):4, 2016. Nightingale F: Notes on nursing: what it is and what it is not, London, 1860, Harrison Sons. QSEN Institute: The evolution of the Quality and Safety Education for Nurses (QSEN) initiative, 2014a. http://qsen.org/ about-qsen/project-overview/. QSEN Institute: Pre-licensure KSAs, 2014b. http://qsen.org/competencies/ pre-licensure-ksas/. Robert Wood Johnson Foundation (RWJF): More newly licensed nurse practitioners choosing to work in primary care, Federal study finds. RWJF, Human Capital Blog, June 10, 2014. http://www.rwjf.org/en/ blogs/human-capital-blog/2014/06/ more_newly_licensed.html. Seo J, et al: Effect of health literacy on decision-making preferences among medically underserved patients, Med Decis Making 36:550, 2016. Sharoff L: Holistic nursing in the genetic/ genomic era, J Holist Nurs 34(2):146, 2016. Sherwood G, Zomorodi M: A new mindset for quality and safety: the QSEN competencies redefine nurses’ roles in practice, J Nurs Adm 44(10):510, 2014. Splendore R, et al: Dress for respect: a shared governance approach, Nurs Manage 47(4):51, 2016. U.S. Census Bureau: Projections of the size and composition of the U.S. population: 2014 to 2060, 2015. http://www.census .gov/content/dam/Census/library/ publications/2015/demo/p25-1143.pdf. West E, et al: Nurse staffing, medical staffing and mortality in intensive care: an observational study, Int J Nurs Stud 51:781, 2014. Westrick SJ: Nursing students’ use of electronic and social media: law, ethics, and e-professionalism, Nurs Educ Perspect 37(1):16, 2016. Yoder-Wise PS: Leading and managing in nursing, ed 5 Revised Reprint, St Louis, 2014, Elsevier. Zerwekh J, Garneau AZ: Nursing today: transition and trends, ed 8, St Louis, 2015, Saunders.
- 37. 15 C H A P T E R 2 Health and Wellness MEDIA RESOURCES http://evolve.elsevier.com/Potter/essentials • Audio Glossary • QSEN Activity and Review Questions Answers O B J E C T I V E S • Discuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients’ attitudes toward health and health practices. • Describe the variables influencing health beliefs, health practices, and illness behaviors. • Describe health promotion and illness prevention activities. • Compare and contrast the three levels of prevention. • Explain how different types of risk factors affect a person’s health. • Describe a nurse’s role in helping patients modify their health risks and change their health behaviors. • Describe variables that influence illness behavior. • Explain how illness affects a patient and family. • Discuss the nurse’s role in caring for people, communities, and populations in various states of health and illness. K E Y T E R M S acute illness, p. 24 chronic illness, p. 24 health, p. 15 health belief model, p. 16 health beliefs, p. 16 health education, p. 20 health promotion, p. 17 health promotion model, p. 16 holistic health, p. 19 illness, p. 24 illness behavior, p. 24 illness prevention, p. 20 Maslow’s hierarchy of needs, p. 17 primary prevention, p. 20 risk factor, p. 21 secondary prevention, p. 21 tertiary prevention, p. 21 Nurses play a key role in helping individuals, families, communities, and populations become or remain healthy. Nurses are considered to be health experts because they are caregivers, advocates, and educators. Health infor- mation is readily available through electronic and print media. However, people often have difficulty determining which information is accurate and helpful. Because health information is so readily available now and because of your expertise in health, your patients, family, and friends will frequently ask you questions about how to use this informa- tion to become healthier. If you can help a person remain well, you can reduce how frequently that person accesses health care, which reduces health care costs. Thus it is very important for nurses to help patients make changes to improve their health and wellness. DEFINITION OF HEALTH The World Health Organization (WHO) defines health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (1947, 2017). Every person has a different definition of health (Pender, et al., 2011). A person who is free from disease is not neces- sarily healthy (Pender, 1996). Health is a state of being influ- enced by a person’s values, personality, and lifestyle. For many people, health is defined by the circumstances surrounding
- 38. 16 UNIT 1 Concepts in Nursing good or bad experiences, or reality or false expectations. Health beliefs influence health behavior and positively or negatively affect a patient’s level of health. Nurses use a variety of health models to understand patients’ beliefs, attitudes, and values about health and illness to provide effective health care. They also allow you to understand and predict patients’ health behavior. Health Belief Model The health belief model (Fig. 2.1) addresses the relationship between a person’s beliefs and behaviors (Rosenstoch, 1974; Becker and Maiman, 1975). It helps you understand and predict how patients will behave in relation to their health and how successful they will be in following suggested therapy or illness management plans. Positive health behaviors are activities related to maintaining,attaining,or regaining health and preventing illness. Common positive health behaviors include getting immunizations, using prescribed and over- the-counter medications properly, maintaining proper sleep patterns, exercising regularly, and eating healthy foods. Implementing positive health behaviors depends on an indi- vidual’s awareness of how to live a healthy life and the ability and willingness to carry out these behaviors. Negative health behaviors include activities that are harmful such as smoking, abusing drugs or alcohol, adopting a sedentary lifestyle, and refusing to take necessary medications. The first component of the health belief model involves an individual’s perception of susceptibility to an illness. The second component is a patient’s perception of the seriousness of that illness. Demographic and sociopsychological vari- ables, perceived threats of an illness, and cues to action (e.g., mass media campaigns and advice from family, friends, and medical professionals) influence and modify this perception. The third component, the likelihood that a patient will take preventive action, results from a patient’s perception of the benefits of and barriers to taking action. Preventive actions include lifestyle changes, increased participation in recom- mended medical therapies, and a search for medical advice or treatment. For example, to apply the health belief model when caring for a patient like Charlie who has a risk for coro- nary artery disease (CAD), Charlie first needs to recognize that family history increases the chances of developing CAD. He needs to believe that CAD is serious to change existing behaviors and implement healthy changes such as following a low-fat diet and increasing exercise to reduce the risk for CAD. The health belief model helps you understand patients’ perceptions, beliefs, and behavior and plan care that will most effectively help patients maintain or restore health and prevent illness. Understand that each patient’s view of health and wellness and individual belief systems influence the ability to make lasting changes in health status. Do not make judgments when you encounter views and beliefs that differ from your own. Health Promotion Model The health promotion model (Fig. 2.2) (Pender, 1982, 1996; Pender et al., 2011) defines health as a positive, dynamic state, their life rather than their physical condition (Pender et al., 2011). Nurses individualize nursing care by considering the whole person and the environment to help patients reach their health goals.Individual perceptions of health are affected by a person’s health beliefs and change as a person ages. For example, the definition of health for older people is often affected by the ability to function independently, the presence of or management of symptoms, acceptance of current health status, being connected to others, and having energy (Song and Kong, 2015). MODELS OF HEALTH AND ILLNESS Models help you understand complex ideas such as health and illness. Thus you use models to understand the relation- ships between health and illness and your patients’ attitudes toward health and health practices. Health beliefs influence health practices. Health beliefs are a person’s ideas, opinions, and attitudes about health and illness. They are sometimes based on facts or misinformation, common sense or myths, Charlie is a 56-year-old retired Navy officer who was recently diagnosed with hyperlipidemia (high cholesterol) and hyper- tension. Knowing that he has a family history of cardiac disease, Charlie has always tried to eat the right foods and exercise, but since retiring he has had difficulty consistently making healthy food choices and exercising regularly. Charlie’s doctor told him he needs to lose 30 lb. Charlie has difficulty exercising daily. His wife still works full time, and they often eat out during the week because of her busy schedule. Charlie comes to the clinic today for a routine visit after starting on medication to reduce his cholesterol. Liz, the cardiac nurse educator, is working with Charlie. Charlie’s total cholesterol level has decreased since starting his medication, but his triglycerides are still high. His blood pressure is also still running on the high side of normal. Liz plans to help Charlie increase his exercise and improve his eating habits to help him develop a healthier lifestyle and reduce his risk for cardiovascular disease. She plans to assess his under- standing of his cardiac risk factors and lifestyle choices and evaluate his readiness to make behavior changes to help him better manage his health. CASE STUDY Charlie
- 39. 17 CHAPTER 2 Health and Wellness (Fig. 2.3). According to Maslow, individuals have to meet lower level needs before they are able to satisfy higher level needs. As people meet the needs of one level, they move up to the next level. Unmet needs motivate human behavior. A person needs to meet basic physiological needs such as oxygen, water, food, sleep, and shelter before progressing to higher level needs. When basic needs are not met, an affected person feels sick or irritated or experiences pain or discom- fort. These feelings motivate an individual to satisfy the need (Maslow, 1970, 1987). The second level on the hierarchy of needs consists of safety and security needs, which include establishing stability and consistency. These psychological needs include the security of a home and a family. For example, a woman in an abusive relationship is unable to move to the next level of love and belongingness because she is constantly concerned for her safety. The third level on the hierarchy, love and belongingness, is a desire to belong to groups. It consists of the need to feel love by others and to be accepted. The fourth level deals with the need for self-esteem. Self-esteem results from mastery of a task and includes the recognition gained from others. The highest level of needs on the hierarchy is self-actualization, which is the desire to become everything that one is capable of becoming. Indi- viduals at this level are concerned with maximizing their potential. Maslow (1970) expanded his model to include cognitive, aesthetic, and transcendence needs to incorporate needs not merely the absence of disease. The model is a framework that integrates the perspectives of nursing with behavioral science and factors that influence health behaviors. You use it with individuals, not communities. Health promotion is behavior motivated by the desire to increase well-being and actualize human health potential, whereas health protection is behavior motivated by a desire to avoid illness, detect it early, or maintain function within the constraints of an illness (Pender et al., 2011). This model describes the multidimensional nature of people as they interact within their environment to pursue health (Pender et al., 2011). The model focuses on three areas: 1. Individual characteristics and experiences 2. Behavior-specific cognitions and affect 3. Behavioral outcomes It also organizes cues into a pattern to explain the likelihood of a patient developing health promotion behaviors (Pender et al., 2011). You can use this model to help your patients carry out healthy behaviors in their daily lives. Basic Human Needs Model Maslow’s hierarchy of needs (Maslow, 1954) helps you understand an individual’s motivation to achieve optimal health. This model explains the basic needs of patients and families, their behaviors, and their readiness to take part in health activities. Maslow’s original model describes human needs using a hierarchical pyramid divided into five levels Individual perceptions Modifying factors Likelihood of action Demographic variables (e.g., age, sex, race, ethnicity) Sociopsychological variables (e.g., personality, social class, peer and reference group pressure) Mass media campaigns Advice from others Reminder postcard from physician or dentist Illness of family member or friend Newspaper or magazine article Cues to action Perceived susceptibility to disease X Perceived seriousness (severity) of disease X Perceived benefits of preventive action Perceived barriers to preventive action minus Likelihood of taking recommended preventive health action Perceived threat of disease X FIG 2.1 Health belief model. (Data from Becker MH, Maiman LA: Sociobehavioral determinants of compliance with health and medical care recommendations, Med Care 13[1]:10, 1975.)
- 40. 18 UNIT 1 Concepts in Nursing that could not be explained by his original model. In the expanded model, cognitive and aesthetic needs come between esteem and self-actualization needs (McLeod, 2016). Accord- ing to Maslow (1970), cognitive needs are hard-wired in all of us and include the needs for knowledge, understand- ing, meaning, and predictability. Aesthetic needs are uni- versal and include the appreciation and search for beauty and balance. Cognitive and aesthetic needs help explain why patients respond better when they understand their health problems (Lorig et al., 2016) and when they are in attractive surroundings with peaceful colors (Slatyer et al., 2015). Tran- scendence needs refer to the need to help others achieve self- actualization and are the highest needs (McLeod, 2016). You can use Maslow’s hierarchy as a framework when addressing patient needs and prioritizing patient care. Unless a patient’s basic needs are met, higher levels in the pyramid are not relevant. Patients approach life differently (Bracken et al., 2015). For example, Charlie in the case study can afford to purchase food, he has a safe home environment, and he has a good relationship with his wife, but he is having trouble INDIVIDUAL CHARACTERISTICS AND EXPERIENCES BEHAVIOR-SPECIFIC COGNITIONS AND AFFECT BEHAVIORAL OUTCOME Prior related behavior Personal factors: biological, psychological, sociocultural Perceived barriers to action Perceived benefits of action Activity-related affect Interpersonal influences (family, peers, providers); norms, support, models Situational influences; options, demand characteristics, aesthetics Perceived self-efficacy Immediate competing demands (low control) and preferences (high control) Commitment to a plan of action Health- promoting behaviors FIG 2.2 Health promotion model. (From Pender NJ, Murdaugh CL, Parsons MA: Health promo- tion in nursing practice, ed 5, Upper Saddle River, NJ, 2006, Prentice Hall.) Self- actualization Self-esteem Love and belonging needs Safety and security Physiological Psychological safety Physical safety Oxygen Fluids Nutrition Body temperature Elimination Shelter Sex FIG 2.3 Maslow’s hierarchy of needs. (From Maslow AH, Frager RD, Fadiman J: Motivation and personality, ed 3. Copyright ©1987. Reprinted by permission of Pearson Educa- tion, Inc., New York, New York.)
- 41. 19 CHAPTER 2 Health and Wellness VARIABLES INFLUENCING HEALTH BELIEFS AND HEALTH PRACTICES Peoples’ beliefs about their own health, their health prac- tices, and the manner in which they care for themselves ultimately influence their health status. Health beliefs are a person’s ideas and attitudes about health (Tovar and Clark, 2015). These beliefs often directly influence health practices whether there is evidence to support them or not. Health practices are activities that individuals perform to care for themselves (Schofield et al., 2016). They include activities of daily living such as bathing and brushing teeth and formal activities such as taking medications and visiting the health care provider for routine checkups. Today health care focuses on the role of patients and their responsibility for self-care. The ability to care for oneself is as important for healthy living as managing a complex medical regimen for a chronic illness. Many variables influence patients’ health beliefs, health practices, and self-care. Internal and external variables influence how a person thinks, acts, and will deal with an illness. Consider the effect of these internal and external variables and incorporate appropriate interven- tions based on a person’s unique characteristics when you deliver nursing care. Internal Variables Developmental Stage. Our concept of illness depends on our developmental stage (see Chapter 23). Knowledge of the stages of growth and development help you predict your patient’s response to an actual illness or the threat of future illness. Your educational interventions need to be age appro- priate as well as developmentally appropriate to be effective. For example, you use different techniques to teach healthy diet choices to a child versus an adult. You also use different techniques for people whose developmental age differs from their chronological age. Intellectual Background. A person’s beliefs about health are shaped in part by knowledge (or misinformation) about body functions and illnesses, educational background, and past experiences. Cognitive abilities shape the way a person thinks, including the ability to understand factors involved in illness and apply knowledge of health and illness to personal health practices. Emotional Factors. A person’s degree of anxiety or stress influences health beliefs and practices. How people handle stress throughout each phase of life influences their personal reaction to illness. A person who generally is very calm may have little emotional response during illness, whereas a person normally unable to cope with stress may overreact to illness or deny the presence of symptoms and does not take therapeutic action (see Chapter 26). Spiritual Factors. Spirituality is a cultural factor reflected in how a person lives his or her life including the values and beliefs exercised, the relationships established with changing his eating habits to reduce his cholesterol. While inter- viewing Charlie,Liz determines that Charlie has low self-esteem. Liz implements interventions to enhance Charlie’s self-esteem to help him realize he needs to change his eating behaviors. The requirements to satisfy the needs of each level of the hierarchy vary from person to person. Therefore you need to thoroughly assess the individual needs of each patient. For example, in caring for patients with psychological issues such as depression or risk for suicide, safety and security needs are a priority. As a nurse, you need to provide all patients with physical and psychological safety (Bracken et al., 2015). Holistic Health Model A person’s health is affected by the relationship between the body, mind, and spirit. Thus nurses and all members of the health care team need to take a holistic view of health by considering the dynamic interaction between the emotional, spiritual, social, cultural, and physical aspects of an individ- ual’s wellness (Chapa et al., 2014). Holistic health views a person as a biopsychosocial and spiritual being (Edelman et al., 2014). The intent of the holistic health model is to empower patients to engage in their own recovery and assume some responsibility for health maintenance (Edelman et al., 2014). The holistic health model includes a variety of techniques recognizing that personal health choices powerfully affect an individual’s health. Some of the most widely used holistic interventions include aromatherapy, biofeedback, breathing exercises, and guided imagery (see Chapter 19). Most holistic therapies are easy to learn and apply to almost any setting and all stages of health and illness. For example, you use reminis- cence to help relieve anxiety in an older patient dealing with memory loss or meditation with a patient dealing with the difficult side effects of chemotherapy. You help patients recognize the many options available and help them make choices to enhance health. HEALTHY PEOPLE DOCUMENTS Forthepast30years,HealthyPeoplehasestablishedevidenced- based objectives to (1) achieve high-quality, longer lives free of disease, disability, injury, and premature death; (2) elimi- nate health disparities; (3) create social and physical environ- ments that promote health for all people; and (4) promote quality of life, healthy development, and healthy behaviors across the life span (Healthy People 2020, 2017). The objec- tives are updated every 10 years to meet a wide range of health needs, encourage collaboration in communities, help indi- viduals make informed health decisions, and measure the impact of prevention activities. Healthy People 2020 includes 26 leading health indicators divided among 12 topic areas to provide a way to assess the health of people in the United States in key areas; encourage collaboration across diverse groups; and motivate action for individuals, communities, and the nation (Healthy People 2020, 2017). The goal is to achieve or make improvements for each objective by 2020.
- 42. 20 UNIT 1 Concepts in Nursing legislation, and policy, to help individuals, groups, and com- munities increase control over and improve their health. It also focuses on improving quality of life, reducing premature death, and reducing costs of medical treatment through its focus on prevention. Health promotion policies or legislation affect all people in a community, state, or country even if the people affected by the policies or laws are not aware of them. For example, bars in a county are required by law to ban smoking to reduce exposure to secondhand smoke. Other health promotion strategies require individuals, groups, or communities to engage in and adopt specific health behaviors. For example, smoking cessation programs require patients to be actively involved in improving their present and future levels of well- ness while decreasing their risk for disease. Health promotion, health education, and illness preven- tion help patients maintain and improve their health,decrease the incidence of illness, and minimize the effects of illness or disability. Health promotion activities such as routine exer- cise and good nutrition help patients maintain or enhance their present levels of health and reduce their risks for devel- oping certain diseases. Health education teaches people how to care for themselves in a healthy way and includes topics such as physical awareness, stress management, and self- responsibility (Box 2.1). Illness prevention protects patients from actual or potential threats to health, such as obtaining immunizations. Health promotion, health education, and illness prevention are closely related and sometimes overlap. All are focused on the future; the differences between them involve motivations and goals. Health promotion activities motivate people to reach more stable levels of health. Health education helps patients achieve new understanding and control of their lives. Illness prevention activities help people avoid declines in health or functional level. Illnesses, particularly chronic illnesses, increase the cost of health care. Improving self-management and providing pre- ventive services reduce health care needs and costs. Therefore you need to educate your patients about improving their ability to improve and manage their health. You do this by helping them recognize the effects their choices have on their health. In the case study, Liz determines Charlie needs more health education. Liz teaches him the importance of diet and exercise to manage his cholesterol and prevent long-term com- plications. She works with Charlie and his wife to develop heart- healthy food choices. Three Levels of Prevention There are three levels of prevention in public health and health promotion. As a nurse, you will provide care in all three levels. Primary prevention is true prevention. Its goal is to reduce the incidence of disease (Edelman et al., 2014; Stanhope and Lancaster, 2016). Many primary prevention activities (e.g., federally funded immunization programs, water treatment) are supported by the government. You provide primary prevention when you provide interventions such as health education to reduce the risk of developing family and friends, and the ability to find hope and meaning in life. Spiritual health often provides motivation to engage in health-promoting activities and enhances mental and physical health during times of illness (Conway-Phillips and Janusek, 2014; Jim et al., 2015; Salsman et al., 2015).You need to understand patients’ spiritual beliefs to incorporate them effectively in nursing care (see Chapter 22). External Variables Culture broadly reflects the whole of human behavior,includ- ing ideas, beliefs, and values about health and illness; ways of relating to one another; language and manners of speaking; and work and lifestyle practices (Ball et al., 2015). A variety of cultural factors influence a patient’s health beliefs and practices. Family Role and Practices. The roles and organization of a family defines the relationship of insiders and outsiders and includes concepts related to family goals and priorities and how each member defines health and illness and values preventive health practices (Chapter 21). There is usually a person in the family responsible for health-related decisions For example, parental health beliefs, attitudes, perceptions, and misperceptions have a direct effect on a family’s health practices. The family’s socioeconomic status, family struc- ture, and parental practices also affect a family’s health (Adamo and Brett, 2014). A person raised in a family that believes in the importance of preventive care such as dental checkups twice a year is more likely to continue those health practices as an adult, whereas parents who have mis- conceptions and unhealthy perceptions about diet quality often contribute to eating habits that lead to obesity (Adamo and Brett, 2014). Socioeconomic Factors. Socioeconomic factors are social determinants of health that increase the risk for illness and influence how a person defines and reacts to illness (see Chapter 21). Socioeconomic variables also determine how and where patients access medical care and receive treatment, how they pay for their health care, and the potential reim- bursement to the health care agency or patient (Lessard et al., 2016). Poor access to health care is one social determinant of health that contributes to health disparities. Economic vari- ables affect a patient’s level of health by increasing the risk for disease and influencing how or at what point the patient enters the health care system. In addition, economic status affects a person’s participation in treatment to maintain or improve health (Hefei et al., 2015). A person who has high utility bills, a large family, and a low income may give a higher priority to food and shelter than to prescribed drugs or treat- ment or foods for special diets. HEALTH PROMOTION, WELLNESS, AND ILLNESS PREVENTION Health promotion is a key component of public health and uses a variety of strategies, such as health education,
- 43. 21 CHAPTER 2 Health and Wellness with an unknown diagnosis of tuberculosis. Screening activi- ties may lead to primary prevention interventions such as providing health teaching. Secondary prevention for Charlie involves having him come to the clinic every year to have his fasting blood sugar and lipid blood levels drawn. Tertiary prevention focuses on reducing complications of long-term disease and disabilities through treatment and rehabilitation (Edelman et al., 2014; Stanhope and Lancaster, 2016). It involves preventing further disability or reduced functioning. Tertiary prevention helps patients achieve as high a level of functioning as possible, despite limitations caused by illness or impairment. For example, you provide tertiary prevention when you help patients who have had a stroke adapt to their impaired mobility so that they can walk and prepare meals again. Risk Factors A risk factor is any attribute, quality, trait, or environmental condition that increases vulnerability of an individual, com- munity, or population to an illness or accident. Risk factors do not cause diseases or accidents, but they increase the chance that an individual, community, or population will experience a particular disease or accident. You assess for risk factors to identify a patient’s health status. A person’s knowl- edge of risk factors sometimes influences health beliefs and practices. People can modify some risk factors such as dietary choices, whereas other risk factors such as genetics or age are nonmodifiable. Nonmodifiable Risk Factors. Nonmodifiable risk factors such as age,gender,genetics,and family history cannot be changed. Use your knowledge of nonmodifiable risk factors to provide secondary prevention. Age increases sus- ceptibility to certain illnesses and accidents. For example, children are at risk for accidental deaths due to drowning. Theriskforheartdisease,diabetes,andmanycancersincreases with age for both genders. Box 2.2 discusses ways to support health promotion in older adults. A person’s gender sometimes is a risk factor for disease or accidents. For example, the risk for asthma is higher in boys than girls. However, by the age of 20, the number of men and women who have asthma is about equal, and by age 40, more women have asthma. Men have a higher risk for cardiovascu- lar disease (CVD) than premenopausal women. However, after menopause, the risk for CVD is similar between men and women. An individual’s family history and genetics are also risk factors for some illnesses. Breast, ovarian, and colon cancer appear to have a genetic link. A person with a family history of diabetes or CVD has a higher risk of developing these diseases. Sometimes it is difficult to determine if the family link to illness is related to genetics, lifestyle choices, or envi- ronmental exposure, or a combination of these factors. For example, you are caring for a female patient with obesity who develops high blood pressure. Her parents have high blood pressure, and her husband smokes. It is challenging for you to determine which risk factor—lifestyle, genetics, or type 2 diabetes. Other examples of primary prevention include ensuring communities have safe water sources,imple- menting bloodborne pathogen regulations, and inspecting restaurants to ensure safe food handling (Stanhope and Lancaster, 2016). For Charlie, primary prevention means reducing his cholesterol through diet and exercise to prevent the development of cardiac disease. Secondary prevention focuses on preventing the spread of disease, illness, or infection once it occurs (Edelman et al., 2014; Stanhope and Lancaster, 2016). Nurses who practice secondary prevention identify and treat people who have new cases of a disease or identify people who have been exposed to a disease but do not have the disease yet. Examples of secondary prevention activities include health screenings and contacting health care employees after exposure to a patient Reducing Cardiac Risk Because she knows that couples with a posi- tive relationship often experience better health, Liz decides to focus her teaching on reducing the risk of developing cardiac disease with Charlie and his wife. OUTCOME • By the end of the visit, Charlie will develop a plan to reduce his cardiac risk factors that is supported by his wife. TEACHING STRATEGIES • Make sure that Charlie and his wife understand his risk for cardiac disease. • Ensure that Charlie understands how risk-reduction strate- gies such as exercise can improve his health (Resnick et al., 2014). • Provide education to Charlie and his wife about risk factor reduction such as a low-fat diet, regular aerobic exercise, and taking medications as prescribed (Sher et al., 2014). • Allow time for Charlie and his wife to discuss any challenges they experience with communication or their relationship (Sher et al., 2014). • Work with the couple to help Charlie set achievable and realistic goals for change (Sher et al., 2014). • Help Charlie and his wife develop problem-solving skills together. Give them problems to solve, such as medication adjustment when Charlie becomes ill or adaptation of diet when a favorite food is not available. • Identify community resources available to Charlie (e.g., walking track, fitness facilities). EVALUATION • Use the principles of teach-back to evaluate the couple’s learning. • “Tell me what changes in your diet the two of you can use to help reduce Charlie’s risk for heart disease.” • “Describe how Charlie can increase his activity level.” • “Tell me how you will work together to make behavioral and relationship changes to help Charlie improve his health.” BOX 2.1 PATIENT TEACHING
- 44. 22 UNIT 1 Concepts in Nursing to obesity will most likely experience the effects of obesity later in life. Patients of all ages are vulnerable to the influences of unhealthy lifestyle patterns. You can influence the choices your patients make to prevent or change unhealthy behaviors and promote healthy lifestyle patterns. Therefore you need to understand the relationship between growth and develop- ment, lifestyle behaviors, and your patients’ health status. Use developmentally appropriate evidence-based interventions when teaching about wellness-promoting lifestyle behaviors (Box 2.3). Environment. The environment is affected by physical, chemical, biological, social, and psychosocial factors. Our environment includes the physical space in which we live; the air, water, soil, and food that is all around us; and the environmental toxins—caused her condition, or if all factors were involved. Modifiable Risk Factors. Some risk factors such as life- style practices and health-related behaviors can be modified. Although some practices can positively affect health, practices with potential negative effects are risk factors. Examples of modifiable risk factors include overeating or poor nutrition, insufficient rest and sleep, and poor personal hygiene. Other habits that put a person at risk for illness include tobacco use, alcohol or drug abuse, and activities involving a threat of injury such as drinking alcohol or texting while driving. Some habits are risk factors for specific diseases. For example, exces- sive sunbathing increases the risk for skin cancer, and being overweight increases the risk for CVD. Examples of modifi- able behavioral risk factors that are leading causes of mortal- ity in the United States include tobacco use, obesity, lack of physical activity, poor control of blood pressure, high choles- terol, and not being immunized for influenza (Johnson et al., 2014). Modifiable risk factors especially for people who are 10 to 24 years of age include behaviors that lead to uninten- tional injuries (e.g., texting while driving, bullying); use of tobacco, alcohol, and other drugs; sexual behaviors leading to unintended pregnancy and sexually transmitted infections; unhealthy diet choices; and physical inactivity (Kann et al., 2016). Current evidence emphasizes the need for preventive care and shows the effect that lifestyle choices have on our health care system, our economy, and our communities. Lifestyle behavior choices affect people throughout their life. For example, a teenager whose nutritional choices lead Importance of Health Promotion • Because individuals are living longer, health promotion activities are important to help maintain function and inde- pendence and improve quality of life. • Partner with appropriate community partners (e.g., churches, agencies that address health inequities) and ensure people providing the education represent the char- acteristics and/or ethnicity of the participants (Boutaugh et al., 2015). • Focus on self-care abilities and practices that foster health while aging and living with a chronic illness (Boutaugh et al., 2015). • Emphasize the need to engage in physical and social activ- ity (Resnick et al., 2014). • Monitor older adults, especially those 75 years of age and older, for high blood pressure, obesity, and diabetes (Resnick et al., 2014). • Promote self-care activities that maintain and improve functional status including management of chronic ill- nesses (Boutaugh et al., 2015). • Ensure health promotion interventions are individualized (Resnick et al., 2014). For example, use the stages of behavior change model (see Table 2.1) to identify older adults who are open to participating in health promotion activities. BOX 2.2 CARE OF THE OLDER ADULT PICO Question: Are individualized developmentally appropriate health promotion interventions effective in increasing patients’ activity levels? SUMMARY OF EVIDENCE Being physically active is important in preventing many health issues such as obesity, cardiovascular disease, cancer, and type 2 diabetes. Many people of all ages do not participate in regular physical activity. Nurses are in key positions to provide health education to patients, families, and communi- ties to promote physical activity. Walking is an activity that people of all ages can usually do and is effective in helping people lose weight or maintain a healthy weight (Adams et al., 2015; Yan et al., 2015). Current evidence shows that effective health promotion interventions are individualized and take a patient’s age and developmental level into consid- eration. Interventions that are effective with younger people are not typically effective with older adults. When high school–age and college-age patients receive positive, indi- vidualized text messages regularly that encourage exercise such as walking and address barriers, goal-setting, motiva- tion, and connection with others, the messages are fre- quently effective in helping patients increase the number of steps they take every day and engage in regular physical activity (Yan et al., 2015; Thompson et al., 2016). Commu- nity-based groups that encourage walking and exercise are often effective in helping middle-aged and elderly patients increase their physical activity (Resnick et al., 2014; Adams et al., 2015). Health promotion interventions that emphasize connections with others are effective in patients of all ages (Resnick et al., 2014; Thompson et al., 2016). APPLICATION TO NURSING PRACTICE • Ensure the health education you provide to your patients is connected to their developmental needs (Yan et al., 2015). • Include connections with significant others when design- ing health promotion strategies for patients of all ages (Resnick et al., 2014). • Encourage patients to set realistic, measurable goals, and encourage them to use pedometers if possible to count their steps daily (Adams et al., 2015). BOX 2.3 EVIDENCE-BASED PRACTICE
- 45. 23 CHAPTER 2 Health and Wellness (pro-change, 2016). When relapse occurs, a person returns to the contemplation or precontemplation stage before attempt- ing change again. Although patients will often feel like relapse is a failure, you need to help them view it as a learning process. Patients can apply what they learned in their next attempt to change. Health promotion interventions have a greater effect if you time them appropriately to match a patient’s specific stage of change (Box 2.4). For example, teaching a patient who is in the contemplation stage and does not routinely eat fruits and vegetables to immediately begin eating five fruits and vegetables a day is not effective. It is better to encourage this patient to think about the costs and benefits of eating five fruits and vegetables a day to help the patient move into the preparation stage. Health care professionals design interventions and well- ness strategies for people in all stages of behavior change. For example, current evidence shows that initiating tobacco ces- sation in hospital settings is very successful (Prochaska et al., 2014). However, if there are no resources or programs avail- able or patients are not aware of available programs, they miss biological, chemical, and radiological exposures we experi- ence. All of these can increase the likelihood that certain illnesses will occur. Some home environments increase the risk that a person will contract and spread infections, whereas some cancers are more likely to develop when people live near toxic waste disposal sites. Environmental exposure rarely occurs one time, in one location, and from one source because we are constantly interacting with our environment (Stanhope and Lancaster, 2016). Risk Factor Identification. You identify modifiable and nonmodifiable risk factors to help patients understand what they need to modify or eliminate to promote wellness and prevent illness. Health risk appraisals assess individuals, fami- lies, or communities for the presence of factors that increase specific health threats.You will often find risk factors through patient interviews and reading medical records. You need to link the risk factors you identify with educational programs and other community resources to help people make lifestyle changes to reduce their risks. In the case study, Liz determines Charlie has several nonmodifiable risk factors for CVD: advanced age, gender, and family history (World Health Federa- tion, 2016). She implements health teaching to help Charlie understand how these factors affect his health. Changing Health Behaviors. Once you identify a patient’s risk factors, you implement appropriate and relevant health education and counseling to help a person change a risky health behavior or implement a new behavior to modify the risk for a disease or injury. It is essential to engage and collaborate with patients when determining which changes they perceive they need to make or are willing to make. Patients typically will not change a behavior unless they see a need and are motivated and supported to change. This will also often require family caregiver support. Aimyourattemptstohelpapatientstopahealth-damaging behavior (e.g., tobacco use or alcohol misuse) or adopt a healthy behavior (e.g., make healthy food choices or exercise) (Pender et al., 2011). Changing health behavior, especially long-term lifestyle habits,is difficult.Adopting healthy behav- iors to reduce risk factors requires patients to change. As a nurse, you are challenged to motivate and facilitate health behavior change in working with individuals, families, and communities (Edelman et al., 2014). Use evidence-based guidelines such as the clinical guidelines and recommenda- tions published by the Agency for Healthcare Research and Quality (AHRQ) (2014), when helping your patients make health behavior changes. You will better help your patients make difficult behavioral changes if you apply knowledge about the process of change. Current evidence supports that many people go through a series of five stages of behavior change (Table 2.1), ranging from precontemplation, when a person has no intention to change, to the maintenance stage, when a person maintains a changed behavior (Prochaska, et al., 2014; pro-change, 2016). Change typically is not a linear process; most people relapse and recycle through the stages of change frequently TABLE 2.1 STAGES OF BEHAVIOR CHANGE STAGE DEFINITION Precontemplation Does not intend to make changes within the next 6 months. Patient is unaware of the problem or underestimates it. “There is nothing that I really need to change.” Contemplation Considering a change within the next 6 months. Patient says that he or she is seriously considering a change. “I have a problem, and I really think I need to work on it.” Preparation Has tried to make changes, but without success. Patient intends to take action in the next month. “I started to exercise regularly, but it didn’t last long. I’ll probably try again in a few weeks.” Action Actively engaged in strategies to change behavior. This stage sometimes lasts up to 6 months. It requires commitment of time and energy. “I am really working hard to stop smoking.” Maintenance Sustained change over time. This stage begins 6 months after action has started and continues indefinitely. It is important to avoid relapse. “I need to avoid people who smoke so I’m not tempted to start smoking again.”
- 46. 24 UNIT 1 Concepts in Nursing United States. Chronic illnesses (e.g., diabetes, heart disease, stroke, cancer, arthritis, obesity) are the most common, costly, and preventable of all health problems in the United States (CDC, 2016). You need to learn how to help patients prevent and manage their chronic illness or disabilities to enhance wellness and improve patients’ quality of life (tertiary prevention). Self-Management Programs that teach chronic disease management must use a holistic approach and include family caregivers when appro- priate. The Chronic Disease Self-Management Program (CDSMP) is one of the most widely used evidence-based programs for people with a variety of chronic illnesses (Lorig et al., 2014). CDSMP is community-based and includes self- management education workshops led by people with the chronic illness. It upholds that people with different chronic illnesses have similar self-management needs and problems, that people can learn how to become responsible for the daily management of their diseases, and that people who are con- fident and knowledgeable about their disease management will have positive health outcomes (Lorig et al., 2014). Taking responsibility for living well with illness strengthens patients. Therefore encourage patients to ask questions about their health care and make informed decisions. The process of learning self-management skills is crucial when learning to live with a chronic illness. The management of chronic ill- nesses promotes health within illness and addresses human comfort and quality of life (Lorig et al., 2016; Williams et al., 2016). You are able to reduce the impact of chronic illness on an individual and society by providing quality, comprehen- sive, patient-centered care (Risendal et al., 2014). Variables Influencing Illness Behavior People have different attitudes and reactions to illness. Medical sociologists call this reaction illness behavior. People who are ill generally adopt illness behaviors (cognitive, affec- tive, and behavioral reactions) that are influenced by socio- cultural and social psychological factors. Illness behaviors affect how people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the health care system. Although people react to an illness in a variety of ways, patients often use illness behavior displayed in sick- ness to manage difficulties in life (Mechanic, 1995). People who have more positive coping skills, greater social support, and a good perceived health status tend to report less illness behaviors (Thomas and Borrayo, 2014). Internal and external variables affect illness behavior. The influences of these variables affect how likely a patient is to seek health care and participate in therapy, which ultimately affects health outcomes. Internal Variables. Internal variables are patients’ per- ceptions of symptoms and the nature of illnesses. If patients believe that the symptoms of their illnesses disrupt their normal routine, they are more likely to seek health care assis- tance than if they do not perceive the symptoms as disruptive. Instead of telling Charlie how much he needs to exercise, Liz applies the stages of behavior change with Charlie to help him become more active. She begins by asking Charlie how he feels about exercise and what his plans are. Charlie states, “I know that exercise is good for me, and I probably should start working on it.” Liz determines Charlie is in the contemplation stage based on his response. She plans her teaching to help Charlie see the benefits of exer- cise, create a plan to fit exercise into his schedule, and find out what kind of activity he prefers. She asks him to bring a list of pros and cons about starting an exercise routine and plans to try some exercises with him at their next appoint- ment. With this process she anticipates Charlie will move into the preparation stage of behavior change within the next month. BOX 2.4 APPLICATION OF THE STAGES OF THE BEHAVIOR CHANGE MODEL the opportunity to make a behavior change to improve their health. Patients maintain changes over time when you help them integrate the changes into their daily routine. True change comes from a patient’s desire to change. Maintenance of healthy lifestyles prevents hospitalizations and potentially lowers the cost of health care. Your advice and support may help patients adapt to a healthier lifestyle. ILLNESS Illness is not the same as disease. Disease is a pathophysiologi- cal process, whereas illness is a state in which a person’s physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired compared with previous experience. A person can feel ill in the presence or absence of disease. For example, cancer is a disease. Some patients with cancer feel ill, whereas others continue to func- tion as usual. Some patients with breast cancer feel well physi- cally but experience spiritual distress. Many patients find health within illness. Sometimes illness motivates an indi- vidual to adopt positive health behaviors. Although you need to be familiar with different types of diseases and their treat- ments, be concerned more with illness, which includes the effects of disease and treatments on a person’s functioning and well-being in all dimensions. Acute and Chronic Illness Acute and chronic illnesses affect many dimensions of func- tioning. An acute illness is usually short-term. The symp- toms appear abruptly, are intense, and often subside after a relatively short period. A chronic illness usually lasts longer than 6 months. Patients fluctuate between maximal func- tioning and serious health relapses that are sometimes life threatening. Because of advances in public health, medicine, and bio- medical technology, acute and infectious diseases are no longer major causes of death, disease, and disability in the
- 47. 25 CHAPTER 2 Health and Wellness change, but it is subtle and does not last long. Some even consider such a change a normal response to illness. Severe illness, particularly one that is life threatening, leads to more extensive emotional and behavioral changes such as anxiety, shock, denial, anger, and withdrawal. These are common responses to the stress of illness. You develop interventions to help patients and families cope with and adapt to this stress because the stressors usually cannot be changed. Impact on Body Image Body image is the subjective concept of physical appearance. Our perception of body image changes as we grow and develop (see Chapter 24). Some illnesses result in changes in physical appearance. Patients and families react differently to these changes. Their reactions depend on the type of changes (e.g., the loss of a limb or an organ), the adaptive capacity of a family, the rate at which changes take place, and the support services available. When a profound change in body image occurs, such as after a mastectomy or leg amputation, a patient generally adjusts by experiencing phases of the grief process (see Chapter 27). Initially the change or impending change shocks the patient. As the patient and family recognize the reality of the change, they become anxious and sometimes withdraw. As they acknowledge the change, they gradually move toward accepting their loss. During rehabilitation, the patient is ready to learn how to adapt to the change in body image. Impact on Self-Concept Self-concept is your mental self-image of all aspects of your personality. It depends in part on body image and roles but also includes other aspects of psychology and spirituality. Self-concept is important in relationships with other family members. A patient whose self-concept changes because of illness is sometimes no longer able to meet family expecta- tions, leading to tension or conflict. As a result, family members change their interactions with the patient. While providing care, you observe changes in a patient’s self-concept (or in the self-concepts of family members) and develop a care plan to help a patient adjust to the changes resulting from the illness (see Chapter 24). Impact on Family Roles and Family Dynamics People have many roles in life such as wage earner, decision maker, professional, and parent. When an illness occurs, the roles of the patient and family change (see Chapter 25). Patients and their families generally adjust more easily to subtle, short-term changes caused by minor acute illness, such as when a child gets strep throat. However, long-term changes caused by sudden acute and severe health problems (e.g., stroke or head injury from a motor vehicle accident) or the diagnosis of a chronic illness (e.g., type 1 diabetes or cancer) require an adjustment process similar to the grief process (see Chapter 27). A patient and family often need specific counseling and guidance to help them cope with the role changes. If they believe that the symptoms are serious or perhaps life threatening, they are also more likely to seek assistance. A person awakened by crushing chest pains in the middle of the night generally views this symptom as potentially serious and life threatening and will probably be motivated to seek assis- tance. However, some patients fear serious illness and react by denying it and not seeking medical assistance. External Variables. External variables influencing a patient’s illness behavior include the visibility of symptoms, social group, cultural variables, accessibility of the health care system, and social support. The visibility of the symptoms of an illness affects body image and illness behavior. A patient with a visible symptom or a recognizable symptom such as crushing chest pain, intense headache, or a high fever is more likely to seek assistance than a patient who has symptoms that are less visible or recognizable such as the nonspecific symp- toms associated with ovarian cancer (e.g., fatigue, bloating, trouble eating, and feeling full quickly) (Mechanic, 1995). Patients’ social groups help them accept or deny the threat of illness. Families, friends, and co-workers all influence patients’ illness behavior. Patients often react positively to social support while practicing positive health behaviors. How patients perceive health and the effects of disease and its interpretation vary according to a patient’s culture and family. Economic variables are social determinants of health that influence the way a patient reacts to illness. Financial diffi- culty will often lead a patient to delay treatment. This is especially common in patients who are uninsured or under- insured. The health care system is a socioeconomic system that patients enter, interact within, and exit. For many patients, entry into the system is complex or confusing, and some patients seek nonemergency medical care in an emer- gency department because they do not have access through insurance or do not know how to obtain health services otherwise. The physical proximity of patients to a health care agency often influences how soon they enter the system after deciding to seek care. IMPACT OF ILLNESS ON PATIENT AND FAMILY An illness of a family member affects the function of an entire family unit. A patient and family commonly experience behavioral and emotional changes and changes in body image, self-concept, family roles, and family dynamics. Behavioral and Emotional Changes Individual behavioral and emotional reactions depend on the nature of an illness, a patient’s attitude toward the illness, the reaction of others to the illness, and the variables of illness behavior. Short-term, non–life-threatening illnesses evoke few behavioral changes in the functioning of a patient or family. For example, a parent who has a severe cold lacks the energy and patience to spend time in family activities and prefers not to interact with the family. This is a behavioral
- 48. 26 UNIT 1 Concepts in Nursing expectations into consideration while developing a plan of care. Understanding your patient’s definition of health builds a trusting and therapeutic relationship, enhancing your ability to help your patients make positive lifestyle choices or behavioral changes. Ensure that health teaching meets your patient’s needs, and provide patient education at a literacy level that your patient can understand (see Chapter 12). You will use the nursing process to develop and implement appro- priate nursing care directed at helping your patients achieve or maintain health or adapt to illness (see Chapter 9). Evalu- ate the effectiveness of your care, taking into consideration whether or not your care met your patient’s expectations. Modify health teaching and health promotion interventions as needed to best meet your patient’s needs. Family dynamics is the process by which the family func- tions, makes decisions, gives support to individual members, and copes with everyday changes and challenges. Because of the effects of illness, family dynamics often change. Another family member sometimes needs to assume a patient’s usual roles and responsibilities.This often creates tension or anxiety in the family. Include the whole family as appropriate while helping patients attain their maximal level of functioning and well-being (see Chapter 25). THE NURSE’S ROLE IN HEALTH AND ILLNESS Patients receive care related to their health and illness needs in all health care settings. Although nurses are often the key members of the health care team to provide information to patients about health, wellness, and illness, patients’ needs are very complex. Thus as a nurse, you need to collaborate with other members of the health care team to successfully improve the health of individuals, families, and communities. Value, respect, and trust the other members of the health care team as you work together to develop an appropriate plan of care. Ensure that a patient’s interests are at the center of the plan. Understand how each team member can contribute to a patient’s health or illness care and determine how you can best work together to help your patient. Effective teams com- municate with and listen to each other clearly and frequently (Interprofessional Education Collaborative Expert Panel, 2011; AHRQ, 2016). Charlie has been attending cardiac edu- cation classes at the clinic for several weeks now. He finds the classes helpful, but he does not understand why so many different people are part of the education team. He has been seeing a nurse, a registered dietitian, a psychologist, and a relaxation therapist. He thinks that it might be easier to just have one person do it all. • How would you explain to Charlie the role of each health care professional on his patient care team? Answers to QSEN Activities can be found on the Evolve website. QSEN ACTIVITY Teamwork and Collaboration K E Y P O I N T S • Health and wellness are not merely the absence of disease and illness. A person’s state of health, wellness, or illness depends on his or her values, attitudes, personality, and lifestyle. • Unmet needs motivate human beings. Basic human needs must be met before an individual is able to focus on higher level needs. • The health promotion model focuses on behaviors moti- vated by the desire to increase well-being and actualize human potential. • Holistic health models of nursing promote optimal health by incorporating active participation of patients in improving their health state. Holistic nursing interven- tions complement standard medical therapy. • Consider internal and external variables that influence patients’ health beliefs and practices when planning nursing care. • Health promotion activities maintain or enhance health. Wellness education teaches patients how to care for them- selves. Illness prevention activities protect against health threats and thus maintain an optimal level of health. • Nursing incorporates health promotion, wellness, and illness prevention activities rather than simply treating illness. • The three levels of prevention are primary (prevention of disease or illness), secondary (minimize spread of disease of illness), and tertiary (long-term management of conditions). • Risk factors threaten health, influence health practices, and are important considerations in illness prevention activities. Some risk factors are modifiable, whereas others are nonmodifiable. • Improvement in health often requires a change in health behaviors. • Illness behavior influences how patients respond to illness. Patients who cope better tend to respond better to illnesses. • Illness has many effects on the patient and family, includ- ing changes in behavior and emotions, family roles and dynamics, body image, and self-concept. You will use your knowledge of various models of health and illness and apply concepts of growth and development to provide individualized effective care that promotes optimal patient outcomes and helps patients achieve the highest level of health possible. Your role in promoting health will vary based on your patient’s needs. Regardless of your practice setting (e.g., hospital, long-term care, school, health depart- ment), you will synthesize what you know to make evidence- based and effective clinical decisions that affect your patient’s care. Whether you are caring for a patient who is healthy or ill, it is important to assess and take your patient’s
- 49. 27 CHAPTER 2 Health and Wellness R E F L E C T I V E L E A R N I N G • Understanding a person’s risk factors helps you determine important information to teach to help that person prevent potential illnesses. Reflect on a patient you recently cared for or think about someone in your family. What actual or potential health problems does this person have? What risk factors contributed to these problems? Can they be modified or not? What health behaviors can this person implement to limit any risk factors? • Interview a patient or someone you know who is the process of changing a health behavior. Ask what behavior this person is thinking about (e.g., smoking cessation, starting an exercise program, losing weight). Find out if the person has begun to make changes yet. Identify which stage of behavior change this person is in based on the information you gain from the interview (see Table 2.1). • Reflect on your own health. How do you define health? Do you consider yourself healthy or not? Explain your answer. What health behaviors would you like to change or imple- ment right now? For example, do you exercise regularly, do you typically make healthy food choices, and are you getting an appropriate amount of sleep right now? Develop a plan to make a behavior change geared toward improv- ing your health status. What are the benefits and possible barriers you will face when you make this change? R E V I E W Q U E S T I O N S 1. Some nursing students are giving flu vaccines to older adults at a retirement village. What level of prevention are the students providing? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Rehabilitation 2. An interprofessional health care team is developing a health education program for a middle school. Which health topics are consistent with the goals of Healthy People 2020? (Select all that apply.) 1. Determining the best treatment for strep throat 2. Explaining why it is important to get immunizations as scheduled 3. Teaching about healthy snacks 4. Describing why genetically modified foods are controversial 5. Teaching different ways to fit exercise into the daily routine 6. Explaining the problems related to lead exposure in the environment 3. When creating a plan of care for a patient with a new below-the-knee amputation, the nurse will consider which factors? (Select all that apply.) 1. The patient and family may grieve the loss of the leg. 2. The patient may have difficulty coping with the change in the appearance of his body. 3. The patient may experience a change in self-concept that will lead to conflict within the family. 4. The patient and family will adjust very quickly and will experience no changes in family dynamics. 5. The loss of the leg will affect only the patient, as the patient is most affected by the change in health status. 4. Which priority nursing intervention is most important to help a patient meet the goal of smoking cessation? 1. Determine if the patient wants to stop smoking. 2. Provide information on the health risks caused by smoking. 3. Include a psychologist to help with implementing this major lifestyle change. 4. Suggest the patient use nicotine-replacement therapy to help with nicotine cravings. 5. The nurse is assessing a patient who has decided to begin running and exercising regularly. Which patient statement reflects the action phase? 1. “I really need to start working out and running to improve my health.” 2. “I went to a gym to talk with a personal trainer and have developed a fitness plan I think will work for me.” 3. “I have been getting up early at least 3 days a week for the past month to exercise for at least 30 minutes every day.” 4. “Now that I have been exercising regularly for the past 7 months, I can tell I have a lot more energy and I have lost weight.” Additional Review Questions, as well as rationales for all Review Questions, can be found on the Evolve website. 1. 1; 2. 2, 3, 5, 6; 3. 1, 2, 3; 4. 1; 5. 3. REFERENCES Adamo K, Brett K: Parental perceptions and childhood dietary quality, Matern Child Health J 18(4):978, 2014. Adams T, et al: A community-based walking program to promote physical activity among African American women, Nurs Womens Health 19(1):26, 2015. Agency for Healthcare Research and Quality (AHRQ): Clinical guidelines and recommendations, 2014, http://www.ahrq .gov/professionals/clinicians-providers/ guidelines-recommendations/index .html. Agency for Healthcare Research and Quality (AHRQ): TeamSTEPPS® 2.0, 2016,
- 50. Other documents randomly have different content
- 51. 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 Rome, bk. i, ch. 14, Eng. tr. 1894, i, 280, for a theory of the extreme antiquity of the alphabet. ↑ Dr. Cheyne (Art. Amos in Encyc. Biblica) gives some good reasons for attaching little weight to such objections, but finally joins in calling Amos “a surprising phenomenon.” ↑ Driver, Introd. to Lit. of Old Test. ch. vi, § 2 (p. 290, ed. 1891). Cp. Kuenen, Relig. of Israel, i, 86; and Robertson Smith, art. Joel, in Encyc. Brit. ↑ Cp. Wellhausen, Israel, p. 501; Driver, ch. vii (1st ed. pp. 352 sq., esp. pp. 355, 361, 362, 365); Stade, Gesch. des Volkes Israel, i, 85. ↑ E.g. Ps. l, 8–15 ; li, 16–17 , where v. 19 is obviously a priestly addition, meant to countervail vv. 16, 17. ↑ Cp. Kuenen, i, 156; Wellhausen, Prolegomena, p. 139; Israel, p. 478. ↑ As to a possible prehistoric connection of Hebrews and Perso-Aryans, see Kuenen, i, 254, discussing Tiele and Spiegel, and iii, 35, 44, treating of Tiele’s view, set forth in his Godsdienst van Zarathustra, that fire-worship was the original basis of Yahwism. Cp. Land’s views, discussed by Kuenen, p. 398; and Renan, Hist. des langues sémit. p. 473. ↑ Cheyne, Introd. to Isaiah, Prol. pp. xxx, xxxviii, following Kosters. ↑ There is a cognate dispute as to the condition of the Samaritans at the time of the Return. Stade (Gesch. den Volkes Israel, i, 602) holds that they were numerous and well- placed. Winckler (Alttestamentliche Untersuchungen, 1892, p. 107) argues that, on the contrary, they were poor and unorganized, and looked to the Jews for help. So also E. Meyer, Gesch. des Alt. iii (1901), 214. ↑ Cp. Rowland Williams, The Hebrew Prophets, ii (1871), 38. This translator’s rendering of the phrase cited by Zephaniah runs: “Neither good does the eternal nor evil.” ↑ Cp. E. Meyer, Geschichte des Alterthums, iii, 216. ↑ Mal. ii, 17 ; iii, 13 . Cp. ii, 8, 11 . ↑ Cp. Jer. xxxiii, 24 ; xxxviii, 19 . ↑ Eccles. iii, 19–21 . ↑ Ch. v. Renan’s translation lends lucidity. ↑ Driver, Introduction, p. 378. Prof. Dillon (Skeptics of the Old Testament, p. 155) goes so far as to pronounce Agur a “Hebrew Voltaire,” which is somewhat of a straining of the
- 52. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 few words he has left. Cp. Dr. Moncure Conway, Solomon and Solomonic Literature, 1899, p. 55. In any case, Agur belongs to an age of “advanced religious reflection” (Cheyne, Job and Solomon, p. 152). ↑ Driver, Introduction, p. 378. ↑ Biscoe, Hist. of the Acts of the Apostles, ed. 1829, p. 80, following Selden and Lightfoot. ↑ S. Schechter, Studies in Judaism, 1896, p. 189, citing Sanhedrin, 386, and Pseudo- Jonathan to Gen. iv, 8 . Cp. pp. 191–92, citing a mention of Epicurus in the Mishna. ↑ The familiar phrase in the Psalms (xiv, i; liii, 1), “The fool hath said in his heart, there is no God,” supposing it to be evidence for anything, clearly does not refer to any reasoned unbelief. Atheism could not well be quite so general as the phrase, taken literally, would imply. ↑ Cp. W. R. Sorley, Jewish Christians and Judaism, 1881, p. 9; Robertson Smith, Old Test. in the Jewish Ch. ed. 1892, pp. 48–49. These writers somewhat exaggerate the novelty of the view they accept. Cp. Biscoe, History of the Acts, ed. 1829, p. 101. ↑ Wisdom, c. 2. ↑ Cp. the implications in Ecclesiasticus, vi, 4–6; xvi, 11–12, as to the ethics of many believers. ↑ Kuenen, ii, 242–43. ↑ Kalisch, Comm. on Leviticus, xxv, 8, pt. ii, p. 548. ↑ In the Wisdom of Solomon, iii, 13; iv, 1, the old desire for offspring is seen to be in part superseded by the newer belief in personal immortality. ↑ Schechter, Studies in Judaism, 1896, p. 216. Compare pp. 193–94. ↑ See Supernatural Religion, 6th ed. i, 97–100, 103–21; Mosheim, Comm. on Christ. Affairs before Constantine, Vidal’s tr. i, 70; Schürer, Jewish People in the Time of Jesus, Eng. tr. Div. II, vol. iii, p. 152. ↑ Sat. xiv, 96–106. ↑ Cp. Horace, 1 Sat. v, 100. ↑ Rev. A. Edersheim, History of the Jewish Nation after the Destruction of Jerusalem, 1856, p. 462, citing the Avoda Sara, a treatise directed against idolatry! Other Rabbinical
- 53. 57 58 views cited by Dr. Edersheim as being in comparison “sublime” are no great improvement on the above—e.g., the conception of deity as “the prototype of the high priest, and the king of kings,”—“who created everything for his own glory.” With all this in view, Dr. Edersheim thought it showed “spiritual decadence” in Philo Judæus to speak of Persian magi and Indian gymnosophists in the same laudatory tone as he used of the Essenes, and to attend “heathenish theatrical representations” (p. 372). ↑ See Ps. xc, 2 ; Prov. viii, 22 , 26 . ↑ This is seen persisting in the lore of the Neo-Platonist writer Sallustius Philosophus (4th c.), De Diis et Mundo, c. 7, though quite unscientifically held. ↑
- 55. Chapter V
- 56. FREETHOUGHT IN GREECE The highest of all the ancient civilizations, that of Greece, was naturally the product of the greatest possible complex of culture-forces;1 and its rise to pre-eminence begins after the contact of the Greek settlers in Æolia and Ionia with the higher civilizations of Asia Minor.2 The great Homeric epos itself stands for the special conditions of Æolic and Ionic life in those colonies;3 even Greek religion, spontaneous as were its earlier growths, was soon influenced by those of the East;4 and Greek philosophy and art alike draw their first inspirations from Eastern contact.5 Whatever reactions we may make against the tradition of Oriental origins,6 it is clear that the higher civilization of antiquity had Oriental (including in that term Egyptian) roots.7 At no point do we find a “pure” Greek civilization. Alike the “Mycenæan” and the “Minoan” civilizations, as recovered for us by modern excavators, show a composite basis, in which the East is implicated.8 And in the historic period the connection remains obvious. It matters not whether we hold the Phrygians and Karians of history to have been originally an Aryan stock, related to the Hellenes, and thus to have acted as intermediaries between Aryans and Semites, or to have been originally Semites, with whom Greeks intermingled.9 On either view, the intermediaries represented Semitic influences, which they passed on to the Greek-speaking races, though they in turn developed their deities in large part on psychological lines common to them and the Semites.10 As to the obvious Asiatic influences on historic Greek civilization, compare Winwood Reade, The Martyrdom of Man, 1872, p. 64; Von Ihering, Vorgeschichte der Indo- Europäer, Eng. tr. (“The Evolution of the Aryan”), p. 73; Schömann, Griech. Alterthümer, 2te Aufl. 1861, i, 10; E. Meyer, Gesch. des Alterth. ii, 155; A. Bertrand, Études de mythol. et d’archéol. grecques, 1858, pp. 40–41; Bury, introd. p. 3. It seems clear that the Egyptian influence is greatly overstated by Herodotos (ii. 49–52, etc.), who indeed avows that he is but repeating what the Egyptians affirm. The Egyptian priests made their claim in the spirit in which the Jews later made theirs. Herodotos, besides, would prefer an Egyptian to an Asiatic derivation, and so would his audience. But it must not be overlooked that there was an Egyptian influence in the “Minoan” period.
- 57. A Hellenistic enthusiasm has led a series of eminent scholars to carry so far their resistance to the tradition of Oriental beginnings11 as to take up the position that Greek thought is “autochthonous.”12 If it were, it could not conceivably have progressed as it did. Only the tenacious psychological prejudice as to race-characters and racial “genius” could thus long detain so many students at a point of view so much more nearly related to supernaturalism than to science. It is safe to say that if any people is ever seen to progress in thought, art, and life, with measurable rapidity, its progress is due to the reactions of foreign intercourse. The primary civilizations, or what pass for such, as those of Akkad and Egypt, are immeasurably slow in accumulating culture-material; the relatively rapid developments always involve the stimulus of old cultures upon a new and vigorous civilization, well-placed for social evolution for the time being. There is no point in early Greek evolution, so far as we have documentary trace of it, at which foreign impact or stimulus is not either patent or inferrible.13 In the very dawn of history the Greeks are found to be a composite stock,14 growing still more composite; and the very beginnings of its higher culture are traced to the non-Grecian people of Thrace,15 who worshipped the Muses. As seen by Herodotos and Thucydides, “the original Hellenes were a particular conquering tribe of great prestige, which attracted the surrounding tribes to follow it, imitate it, and call themselves by its name. The Spartans were, to Herodotos, Hellenic; the Athenians, on the other hand, were not. They were Pelasgian, but by a certain time ‘changed into Hellenes and learnt their language.’ In historical times we cannot really find any tribe of pure Hellenes in existence.”16 The later supremacy of the Greek culture is thus to be explained in terms not of an abnormal “Greek genius,”17 but of the special evolution of intelligence in the Greek-speaking stock, firstly through constant crossing with others, and secondarily through its furtherance by the special social conditions of the more progressive Greek city-states, of which conditions the most important were their geographical dividedness and their own consequent competition and interaction.18 The whole problem of Oriental “influence” has been obscured, and the solution retarded, by the old academic habit of discussing questions of mental evolution in vacuo. Even the
- 58. reaction against idolatrous Hellenism proceeded without due regard to historical sequence; and the return reaction against that is still somewhat lacking in breadth of inference. There has been too much on one side of assumption as to early Oriental achievement; and too much tendency on the other to assume that the positing of an “influence” on the Greeks is a disparagement of the “Greek mind.” The superiority of that in its later evolution seems too obvious to need affirming. But that hardly justifies so able a writer as Professor Burnet in concluding (Early Greek Philosophy, 2nd ed. introd. pp. 22–23) that “the” Egyptians knew no more arithmetic than was learned by their children in the schools; or in saying (id. p. 26) that “the” Babylonians “studied and recorded celestial phenomena for what we call astrological purposes, not from any scientific interest.” How can we have the right to say that no Babylonians had a scientific interest in the data? Such interest would in the nature of the case miss the popular reproduction given to astrological lore. But it might very well subsist. Professor Burnet, albeit a really original investigator, has not here had due regard to the early usage of collegiate or corporate culture, in which arcane knowledge was reserved for the few. Thus he writes (p. 26) concerning the Greeks that “it was not till the time of Plato that even the names of the planets were known.” Surely they must have been “known” to some adepts long before: how else came they to be accepted? As Professor Burnet himself notes (p. 34), “in almost every department of life we find that the corporation at first is everything and the individual nothing. The peoples of the East hardly got beyond this stage at all: their science, such as it is, is anonymous, the inherited property of a caste or guild, and we still see clearly in some cases that it was once the same among the Hellenes.” Is it not then probable that astronomical knowledge was so ordered by Easterns, and passed on to Hellenes? There still attaches to the investigation of early Greek philosophy the drawback that the philosophical scholars do not properly posit the question: What was the early Ionic Greek society like? How did the Hellenes relate to the older polities and cultures which they found there? Professor Burnet makes justifiable fun (p. 21, note) of Dr. Gomperz’s theory of the influence of “native brides”; but he himself seems to argue that the Greeks could learn nothing from the men they conquered, though he admits (p. 20) their derivation of “their art and many of their religious ideas from the East.” If religion, why not religious speculation, leading to philosophy and science? This would be a more fruitful line of inquiry than one based on the assumption that “the” Babylonians went one way and “the” Greeks another. After all, only a few in each race carried on the work of thought and discovery. We do not say that “the English” wrote Shakespeare. Why affirm always that “the” Greeks did whatever great Greeks achieved? On the immediate issue Professor Burnet incidentally concedes what is required. After arguing that the East perhaps borrowed more from the West than did the West from the East, he admits (p. 21): “It would, however, be quite another thing to say that Greek philosophy originated quite independently of Oriental influence.”
- 59. § 1 By the tacit admission of one of the ablest opponents of the theory of foreign influence, Hellenic religion as fixed by Homer for the Hellenic world was partly determined by Asiatic influences. Ottfried Müller decided not only that Homer the man (in whose personality he believed) was probably a Smyrnean, whether of Æolic or Ionic stock,19 but that Homer’s religion must have represented a special selection from the manifold Greek mythology, necessarily representing his local bias.20 Now, the Greek cults at Smyrna, as in the other Æolic and Ionic cities of Asia Minor, would be very likely to reflect in some degree the influence of the Karian or other Asiatic cults around them.21 The early Attic conquerors of Miletos allowed the worship of the Karian Sun-God there to be carried on by the old priests; and the Attic settlers of Ephesos in the same way adopted the neighbouring worship of the Lydian Goddess (who became the Artemis or “Great Diana” of the Ephesians), and retained the ministry of the attendant priests and eunuchs.22 Smyrna was apparently not like these a mixed community, but one founded by Achaians from the Peloponnesos; but the genera] Ionic and Æolic religious atmosphere, set up by common sacrifices,23 must have been represented in an epic brought forth in that region. The Karian civilization had at one time spread over a great part of the Ægean, including Delos and Cyprus.24 Such a civilization must have affected that of the Greek conquerors, who only on that basis became civilized traders.25 It is not necessary to ask how far exactly the influence may have gone in the Iliad: the main point is that even at that stage of comparatively simple Hellenism the Asiatic environment, Karian or Phoenician, counted for something, whether in cosmogony or in furthering the process of God- grouping, or in conveying the cult of Cyprian Aphrodite,26 or haply in lending some characteristics to Zeus and Apollo and Athênê,27 an influence
- 60. none the less real because the genius of the poet or poets of the Iliad has given to the whole Olympian group the artistic stamp of individuality which thenceforth distinguishes the Gods of Greece from all others. Indeed, the very creation of a graded hierarchy out of the independent local deities of Greece, the marrying of the once isolated Pelasgic Hêrê to Zeus, the subordination to him of the once isolated Athênê and Apollo—all this tells of the influence of a Semitic world in which each Baal had his wife, and in which the monarchic system developed on earth had been set up in heaven.28 But soon the Asiatic influence becomes still more clearly recognizable. There is reason to hold with Schrader that the belief in a mildly blissful future state, as seen even in the Odyssey29 and in the Theogony ascribed to Hesiod,30 is “a new belief which is only to be understood in view of oriental tales and teaching.”31 In the Theogony, again, the Semitic element increases,32 Kronos being a Semitic figure;33 while Semelê, if not Dionysos, appears to be no less so.34 But we may further surmise that in Homer, to begin with, the conception of Okeanos, the earth-surrounding Ocean-stream, as the origin of all things,35 comes from some Semitic source; and that Hesiod’s more complicated scheme of origins from Chaos is a further borrowing of oriental thought—both notions being found in ancient Babylonian lore, whence the Hebrews derived their combination of Chaos and Ocean in the first verses of Genesis.36 It thus appears that the earlier oriental37 influence upon Greek thought was in the direction of developing religion,38 with only the germ of rationalism conveyed in the idea of an existence of matter before the Gods,39 which we shall later find scientifically developed. But the case is obscure. Insofar as the Theogony, for instance, partly moralizes the more primitively savage myths,40 it may be that it represents the spontaneous need of the more highly evolved race to give an acceptable meaning to divine tales which, coming from another race, have not a quite sacrosanct prescription, though the tendency is to accept them. On the other hand, it may have been a further foreign influence that gave the critical impulse. “It is plain enough that Homer and Hesiod represent, both theologically and socially, the close of a long epoch, and not the youth of the Greek world, as some have supposed. The real signification of many myths is lost to them, and so is the import of most of the names
- 61. and titles of the elder Gods, which are archaic and strange, while the subordinate personages generally have purely Greek names” (Professor Mahaffy, History of Classical Greek Literature, 1880, i, 17). § 2 Whatever be the determining conditions, it is clear that the Homeric epos stands for a new growth of secular song, distinct from the earlier poetry, which by tradition was “either lyrical or oracular.” The poems ascribed to the pre-Homeric bards “were all short, and they were all strictly religious. In these features they contrasted broadly with the epic school of Homer. Even the hexameter metre seems not to have been used in these old hymns, and was called a new invention of the Delphic priests.41 Still further, the majority of these hymns are connected with mysteries apparently ignored by Homer, or with the worship of Dionysos, which he hardly knew.”42 Intermediate between the earlier religious poetry and the Homeric epic, then, was a hexametric verse, used by the Delphic priesthood; and to this order of poetry belongs the Theogony which goes under the name of Hesiod, and which is a sample of other and older works,43 probably composed by priests. And the distinctive mark of the Homeric epos is that, framed as it was to entertain feudal chiefs and their courts, it turned completely away from the sacerdotal norm and purpose. “Thus epic poetry, from having been purely religious, became purely secular. After having treated men and heroes in subordination to the Gods, it came to treat the Gods in relation to men. Indeed, it may be said of Homer that in the image of man created he God.”44 As to the non-religiousness of the Homeric epics, there is a division of critical opinion. Meyer insists (Gesch. des Alt. ii, 395) that, as contrasted with the earlier religious poetry, “the epic poetry is throughout secular (profan); it aims at charming its hearers, not at propitiating the Gods”; and he further sees in the whole Ionian mood a certain cynical disillusionment (id. ii, 723). Cp. Benn, Philos. of Greece, p. 40, citing Hegel. E. Curtius (G. G. i, 126) goes so far as to ascribe a certain irony to the portraiture of the Gods (Ionian
- 62. Apollo excepted) in Homer, and to trace this to Ionian levity. To the same cause he assigns the lack of any expression of a sense of stigma attaching to murder. This sense he holds the Greek people had, though Homer does not hint it. (Cp. Grote, i, 24, whose inference Curtius implicitly impugns.) Girard (Le Sentiment religieux en Grèce, 1869), on the contrary, appears to have no suspicion of any problem to solve, treating Homer as unaffectedly religious. The same view is taken by Prof. Paul Decharme. “On chercherait vainement dans l’Iliade et dans l’Odyssée les premières traces du scepticisme grec à l’égard des fables des dieux. C’est avec une foi entière en la réalité des événements mythiques que les poètes chantent les légendes ...; c’est en toute simplicité d’âme aussi que les auditeurs de l’épopée écoutent....” (La critique des traditions religieuses chez les grecs, 1904, p. 1.) Thus we have a kind of balance of contrary opinions, German against French. Any verdict on the problem must recognize on the one hand the possibilities of naïve credulity in an unlettered age, and on the other the probability of critical perception on the part of a great poet. I have seen both among Boers in South Africa. On the general question of the mood of the Homeric poems compare Gilbert Murray, Four Stages of Greek Religion, 1912, p. 77, and Hist. of Anc. Greek Lit. pp. 34, 35; and A. Benn, The Philosophy of Greece in Relation to the Character of its People, 1898, pp. 29–30. Still, it cannot be said that in the Iliad there is any clear hint of religious skepticism, though the Gods are so wholly in the likeness of men that the lower deities fight with heroes and are worsted, while Zeus and Hêrê quarrel like any earthly couple. In the Odyssey there is a bare hint of possible speculation in the use of the word atheos; but it is applied only in the phrase οὐκ ἀθεεὶ, “not without a God,”45 in the sense of similar expressions in other passages and in the Iliad.46 The idea was that sometimes the Gods directly meddled. When Odysseus accuses the suitors of not dreading the Gods,47 he has no thought of accusing them of unbelief.48 Homer has indeed been supposed to have exercised a measure of relative freethought in excluding from his song the more offensive myths about the Gods,49 but such exclusion may be sufficiently explained on the score that the epopees were chanted in aristocratic dwellings, in the presence of womenkind, without surmising any process of doubt on the poet’s part. On the other hand, it was inevitable that such a free treatment of things hitherto sacred should not only affect the attitude of the lay listener towards the current religion, but should react on the religious consciousness. God- legends so fully thrust on secular attention were bound to be discussed; and
- 63. in the adaptations of myth for liturgical purposes by Stesichoros (fl. circa 600 B.C.) we appear to have the first open trace of a critical revolt in the Greek world against immoral or undignified myths.50 In his work, it is fair to say, we see “the beginning of rationalism”: “the decisive step is taken: once the understanding criticizes the sanctified tradition, it raises itself to be the judge thereof; no longer the common tradition but the individual conviction is the ground of religious belief.”51 Religious, indeed, the process still substantially is. It is to preserve the credit of Helena as a Goddess that Stesichoros repudiates the Homeric account of her,52 somewhat in the spirit in which the framers of the Hesiodic theogony manipulated the myths without rejecting them, or the Hebrew redactors tampered with their text. But in Stesichoros there is a new tendency to reject the myth altogether;53 so that at this stage freethought is still part of a process in which religious feeling, pressed by an advancing ethical consciousness, instinctively clears its standing ground. It is in Pindar, however (518–442 B.C.), that we first find such a mental process plainly avowed by a believer. In his first Olympic Ode he expressly declares the need for bringing afterthought to bear on poetic lore, that so men may speak nought unfitting of the Gods; and he protests that he will never tell the tale of the blessed ones banqueting on human flesh.54 In the ninth Ode he again protests that his lips must not speak blasphemously of such a thing as strife among the immortals.55 Here the critical motive is ethical, though, while repudiating one kind of scandal about the Gods, Pindar placidly accepts others no less startling to the modern sense. His critical revolt, in fact, is far from thoroughgoing, and suggests rather a religious man’s partial response to pressure from others than any independent process of reflection.56 “He [Pindar] was honestly attached to the national religion and to its varieties in old local cults. He lived a somewhat sacerdotal life, labouring in honour of the Gods, and seeking to spread a reverence for old traditional beliefs. He, moreover, shows an acquaintance with Orphic rites and Pythagorean mysteries, which led him to preach the doctrine of immortality, and of rewards and punishments in the life hereafter. [Note.—The most explicit fragment (θρῆνοι, 3), is, however, not considered genuine by recent critics.]... He is indeed more affected by the advance of freethinking than he imagines; he borrows from the
- 64. neologians the habit of rationalizing myths, and explaining away immoral acts and motives in the Gods; but these things are isolated attempts with him, and have no deep effect upon his general thinking” (Mahaffy, Hist. of Greek Lit. i, 213–14). For such a development we are not, of course, forced to assume a foreign influence: mere progress in refinement and in mental activity could bring it about; yet none the less it is probable that foreign influence did quicken the process. It is true that from the beginnings of the literary period Greek thought played with a certain freedom on myth, partly perhaps because the traditions visibly came from various races, and there was no strong priesthood to ossify them. After Homer and Hesiod, men looked back to those poets as shaping theology to their own minds.57 But all custom is conservative, and Pindar’s mind had that general cast. On the other hand, external influence was forthcoming. The period of Pindar and Æschylus [525–455 B.C.] follows on one in which Greek thought, stimulated on all sides, had taken the first great stride in its advance beyond all antiquity. Egypt had been fully thrown open to the Greeks in the reign of Psammetichos58 (650 B.C.); and a great historian, who contends that the “sheer inherent and expansive force” of “the” Greek intellect, “aided but by no means either impressed or provoked from without,” was the true cause, yet concedes that intercourse with Egypt “enlarged the range of their thoughts and observations, while it also imparted to them that vein of mysticism which overgrew the primitive simplicity of the Homeric religion,” and that from Asia Minor in turn they had derived “musical instruments and new laws of rhythm and melody,” as well as “violent and maddening religious rites.”59 And others making similar à priori claims for the Greek intelligence are forced likewise to admit that the mental transition between Homer and Herodotos cannot be explained save in terms of “the influence of other creeds, and the necessary operation of altered circumstances and relations.”60 In the Persae of Æschylus we even catch a glimpse of direct contact with foreign skepticism;61 and again in the Agamemnon there is a reference to some impious one who denied that the Gods deigned to have care of mortals.62 It seems unwarrantable to read as “ridicule of popular polytheism” the passage in the same tragedy:63 “Zeus, whosoever he be; if this name be well-pleasing to himself in invocation, by
- 65. this do I name him.” It may more fitly be read64 as an echo of the saying of Herakleitos that “the Wise [= the Logos?] is unwilling and willing to be called by the name of Zeus.”65 But in the poet’s thought, as revealed in the Prometheus, and in the Agamemnon on the theme of the sacrifice of Iphigeneia, there has occurred an ethical judgment of the older creeds, an approach to pantheism, a rejection of anthropomorphism, and a growth of pessimism that tells of their final insufficiency. The leaning to pantheism is established by the discovery that the disputed lines, “Zeus is sky, earth, and heaven: Zeus is all things, yea, greater than all things” (Frag. 443), belonged to the lost tragedy of the Heliades (Haigh, Tragic Drama of the Greeks, 1896, p. 88). For the pessimism see the Prometheus, 247–51. The anti-anthropomorphism is further to be made out from the lines ascribed to Æschylus by Justin Martyr (De Monarchia, c. 2) and Clemens Alexandrinus (Stromata, v, 14). They are expressly pantheistic; but their genuineness is doubtful. The story that Æschylus was nearly killed by a theatre audience on the score that he had divulged part of the mysteries in a tragedy (Haigh, The Attic Theatre, 1889, p. 316; Tragic Drama, pp. 49–50) does not seem to have suggested to Aristotle, who tells it (Nicomachean Ethics, iii, 2), any heterodox intention on the tragedian’s part; but it is hard to see an orthodox believer in the author either of the Prometheus, wherein Zeus is posed as brutal might crucifying innocence and beneficence, or of the Agamemnon, where the father, perplexed in the extreme, can but fall back helplessly on formulas about the all-sufficiency of Zeus when called upon to sacrifice his daughter. Cp. Haigh, Tragic Drama, p. 86 sq. “Some critics,” says Mr. Haigh (p. 88), “have been led to imagine that there is in Æschylus a double Zeus—the ordinary God of the polytheistic religion and the one omnipotent deity in whom he really believed. They suppose that he had no genuine faith in the credibility of the popular legends, but merely used them as a setting for his tragedies; and that his own convictions were of a more philosophical type,” as seen in the pantheistic lines concerning Zeus. To this Mr. Haigh replies that it is “most improbable that there was any clear distinction in the mind of Æschylus” between the two conceptions of Zeus; going on, however, to admit that “much, no doubt, he regarded as uncertain, much as false. Even the name ‘Zeus’ was to him a mere convention.” Mr. Haigh in this discussion does not attempt to deal with the problem of the Prometheus. The hesitations of the critics on this head are noteworthy. Karl Ottfried Müller, who is least himself in dealing with fundamental issues of creed, evades the problem (Lit. of Anc. Greece, 1847, p. 329) with the bald suggestion that “Æschylus, in his own mind, must have felt how this severity [of Zeus], a necessary accompaniment of the transition from the Titanic period to the government of the Gods of Olympus, was to be reconciled with the mild wisdom which he makes an attribute of Zeus in the subsequent ages of the world. Consequently, the deviation from right ... would all lie on the side of Prometheus.” This
- 66. nugatory plea—which is rightly rejected by Burckhardt (Griech. Culturgesch. ii, 25)—is ineffectually backed by the argument that the friendly Oceanides recur to the thought, “Those only are wise who humbly reverence Adrasteia (Fate)”—as if the positing of a supreme Fate were not a further belittlement of Zeus. Other critics are similarly evasive. Patin (Eschyle, éd. 1877, p. 250 sq.), noting the vagaries of past criticism, hostile and other, avowedly leaves the play an unsolved enigma, affirming only the commonly asserted “piety” of Æschylus. Girard (Le sentiment religieux en Grèce, pp. 425–29) does no better, while dogmatically asserting that the poet is “the Greek faithful to the faith of his fathers, which he interprets with an intelligent and emotional (émue) veneration.” Meyer (iii, §§ 257–58) draws an elaborate parallel between Æschylus and Pindar, affirming in turn the “tiefe Frömmigkeit” of the former—and in turn leaves the enigma of the Prometheus unsolved. Professor Decharme, rightly rejecting the fanciful interpretations of Quinet and others who allegorize Prometheus into humanity revolting against superstition, offers a very unsatisfying explanation of his own (p. 107), which practically denies that there is any problem to solve. Prof. Mahaffy, with his more vivacious habit of thought, comes to the evaded issue. “How,” he asks, “did the Athenian audience, who vehemently attacked the poet for divulging the mysteries, tolerate such a drama? And still more, how did Æschylus, a pious and serious thinker, venture to bring such a subject on the stage with a moral purpose?” The answers suggested are: (1) that in all old religions there are tolerated anomalous survivals; (2) that “a very extreme distortion of their Gods will not offend many who would feel outraged at any open denial of them”; (3) that all Greeks longed for despotic power for themselves, and that “no Athenian, however he sympathized with Prometheus, would think of blaming Zeus for ... crushing all resistance to his will.” But even if these answers—of which the last is the most questionable—be accepted, “the question of the poet’s intention is far more difficult, and will probably never be satisfactorily answered.” Finally, we have this summing-up: “Æschylus was, indeed, essentially a theologian ... but, what is more honourable and exceptional, he was so candid and honest a theologian that he did not approach men’s difficulties for the purpose of refuting them or showing them weak and groundless. On the contrary, though an orthodox and pious man, though clearly convinced of the goodness of Providence, and of the profound truth of the religion of his fathers, he was ever stating boldly the contradictions and anomalies in morals and in myths, and thus naturally incurring the odium and suspicion of the professional advocates of religion and their followers. He felt, perhaps instinctively, that a vivid dramatic statement of these problems in his tragedies was better moral education than vapid platitudes about our ignorance, and about our difficulties being only caused by the shortness of our sight” (Hist. of Greek Lit. i, 260–61, 273–74). Here, despite the intelligent handling, the enigma is merely transferred from the great tragedian’s work to his character: it is not solved. No solution is offered of the problem of the pantheism of the fragment above cited, which is quite irreconcilable with any orthodox
- 67. belief in Greek religion, though such sayings are at times repeated by unthinking believers, without recognition of their bearing. That the pantheism is a philosophical element imported into the Greek world from the Babylonian through the early Ionian thinkers seems to be the historical fact (cp. Whittaker, as last cited): that the importation meant the dissolution of the national faith for many thinking men seems to be no less true. It seems finally permissible, then, to suggest that the “piety” of Æschylus was either discontinuous or a matter of artistic rhetoric and public spirit, and that the Prometheus is a work of profound and terrible irony, unburdening his mind of reveries that religion could not conjure away. The discussion on the play has unduly ignored the question of its date. It is, in all probability, one of the latest of the works of Æschylus (K. O. Müller, Lit. of Anc. Greece, p. 327; Haigh, Tragic Drama, p. 109). Müller points to the employment of the third actor—a late development—and Haigh to the overshadowing of the choruses by the dialogue; also to the mention (ll. 366–72) of the eruption of Etna, which occurred in 475 B.C. This one circumstance goes far to solve the dispute. Written near the end of the poet’s life the play belongs to the latest stages of his thinking; and if it departs widely in its tone from the earlier plays, the reasonable inference is that his ideas had undergone a change. The Agamemnon, with its desolating problem, seems to be also one of his later works. Rationalism, indeed, does not usually emerge in old age, though Voltaire was deeply shaken in his theism by the earthquake of Lisbon; but Æschylus is unique even among men of genius; and the highest flight of Greek drama may well stand for an abnormal intellectual experience. In this primary entrance of critical doubt into drama we have one of the sociological clues to the whole evolution of Greek thought. It has been truly said that the constant action of the tragic stage, the dramatic putting of arguments and rejoinders, pros and cons—which in turn was a fruit of the actual daily pleadings in the Athenian dikastery—was a manifold stimulus alike to ethical feeling and to intellectual effort, such as no other ancient civilization ever knew. “The appropriate subject-matter of tragedy is pregnant not only with ethical sympathy, but also with ethical debate and speculation,” to an extent unapproached in the earlier lyric and gnomic poetry and the literature of aphorism and precept. “In place of unexpanded results, or the mere communication of single-minded sentiment, we have even in Æschylus, the earliest of the great tragedians, a large latitude of dissent and debate—a shifting point of view—a case better or worse—and a divination of the future advent of sovereign and instructed reason. It was through the intermediate stage of tragedy that Grecian literature passed into the Rhetoric, Dialectics, and Ethical speculation which marked the fifth century B.C.”66
- 68. This development was indeed autochthonous, save insofar as the germ of the tragic drama may have come from the East in the cult of Dionysos, with its vinous dithyramb: the “Greek intellect” assuredly did wonderful things at Athens, being placed, for a time, in civic conditions peculiarly fitted for the economic evocation of certain forms of genius. But the above-noted developments in Pindar and in Æschylus had been preceded by the great florescence of early Ionian philosophy in the sixth century, a growth which constrains us to look once more to Asia Minor for a vital fructification of the Greek inner life, of a kind that Athenian institutions could not in themselves evoke. For while drama flourished supremely at Athens, science and philosophy grew up elsewhere, centuries before Athens had a philosopher of note; and all the notable beginnings of Hellenic freethought occurred outside of Hellas proper. § 3 The Greeks varied from the general type of culture-evolution seen in India, Persia, Egypt, and Babylon, and approximated somewhat to that of ancient China, in that their higher thinking was done not by an order of priests pledged to cults, but by independent laymen. In Greece, as in China, this line of development is to be understood as a result of early political conditions—in China, those of a multiplicity of independent feudal States; in Greece, those of a multiplicity of City States, set up first by the geographical structure of Hellas, and reproduced in the colonies of Asia Minor and Magna Graecia by reason of the acquired ideal and the normal state of commercial competition. To the last, many Greek cults exhibited their original character as the sacra of private families. Such conditions prevented the growth of a priestly caste or organization.67 Neither China nor Pagan Greece was imperialized till there had arisen enough of rationalism to prevent the rise of a powerful priesthood; and the later growth of a priestly system in Greece in the Christian period is to be explained in terms first of a positive social degeneration, accompanying a
- 69. complete transmutation of political life, and secondly of the imposition of a new cult, on the popular plane, specially organized on the model of the political system that adopted it. Under imperialism, however, the two civilizations ultimately presented a singular parallel of unprogressiveness. In the great progressive period, the possible gains from the absence of a priesthood are seen in course of realization. For the Greek-speaking world in general there was no dogmatic body of teaching, no written code of theology and moral law, no Sacred Book.68 Each local cult had its own ancient ritual, often ministered by priestesses, with myths, often of late invention, to explain it;69 only Homer and Hesiod, with perhaps some of the now lost epics, serving as a general treasury of myth-lore. The two great epopees ascribed to Homer, indeed, had a certain Biblical status; and the Homerids or other bards who recited them did what in them lay to make the old poetry the standard of theological opinion; but they too lacked organized influence, and could not hinder higher thinking.70 The special priesthood of Delphi, wielding the oracle, could maintain their political influence only by holding their function above all apparent self-seeking or effort at domination.71 It only needed, then, such civic conditions as should evolve a leisured class, with a bent towards study, to make possible a growth of lay philosophy. Those conditions first arose in the Ionian cities; because there first did Greek citizens attain commercial wealth,72 as a result of adopting the older commercial civilization whose independent cities they conquered, and of the greater rapidity of development which belongs to colonies in general.73 There it was that, in matters of religion and philosophy, the comparison of their own cults with those of their foreign neighbours first provoked their critical reflection, as the age of primitive warfare passed away. And there it was, accordingly, that on a basis of primitive Babylonian science there originated with Thales of Miletos (fl. 586 B.C.), a Phoenician by descent,74 the higher science and philosophy of the Greek-speaking race.75 It is historically certain that Lydia had an ancient and close historical connection with Babylonian and Assyrian civilization, whether through the “Hittites” or otherwise (Sayce, Anc. Emp. of the East, 1884, pp. 217–19; Curtius, Griech. Gesch. i, 63, 207; Meyer, Gesch.
- 70. des Alterth. i, 166, 277, 299, 305–10; Soury, Bréviaire de l’hist. du matérialisme, 1881, pp. 30, 37 sq. Cp. as to Armenia, Edwards, The Witness of Assyria, 1893, p. 144); and in the seventh century the commercial connection between Lydia and Ionia, long close, was presumably friendly up to the time of the first attacks of the Lydian Kings, and even afterwards (Herodotos i, 20–23), Alyattes having made a treaty of peace with Miletos, which thereafter had peace during his long reign. This brings us to the time of Thales (640– 548 B.C.). At the same time, the Ionian settlers of Miletos had from the first a close connection with the Karians (Herod. i, 146, and above pp. 120–21), whose near affinity with the Semites, at least in religion, is seen in their practice of cutting their foreheads at festivals (id. ii, 61; cp. Grote, ed. 1888, i, 27, note; E. Curtius, i, 36, 42; Busolt, i, 33; and Spiegel, Eranische Alterthumskunde, i, 228). Thales was thus in the direct sphere of Babylonian culture before the conquest of Cyrus; and his Milesian pupils or successors, Anaximandros and Anaximenes, stand for the same influences. Herakleitos in turn was of Ephesus, an Ionian city in the same culture-sphere; Anaxagoras was of Klazomenai, another Ionian city, as had been Hermotimos, of the same philosophic school; the Eleatic school, founded by Xenophanes and carried on by Parmenides and the elder Zeno, come from the same matrix, Elea having been founded by exiles from Ionian Phokaia on its conquest by the Persians; and Pythagoras, in turn, was of the Ionian city of Samos, in the same sixth century. Finally, Protagoras and Demokritos were of Abdera, an Ionian colony in Thrace; Leukippos, the teacher of Demokritos, was either an Abderite, a Milesian, or an Elean; and Archelaos, the pupil of Anaxagoras and a teacher of Sokrates, is said to have been a Milesian. Wellhausen (Israel, p. 473 of vol. of Prolegomena, Eng. tr.) has spoken of the rise of philosophy on the “threatened and actual political annihilation of Ionia” as corresponding to the rise of Hebrew prophecy on the menace and the consummation of the Assyrian conquest. As regards Ionia, this may hold in the sense that the stoppage of political freedom threw men back on philosophy, as happened later at Athens. But Thales philosophized before the Persian conquest. § 4 Thales, like Homer, starts from the Babylonian conception of a beginning of all things in water; but in Thales the immediate motive and the sequel are strictly cosmological and neither theological nor poetical, though we cannot tell whether the worship of a God of the Waters may not have been the origin of a water-theory of the cosmos. The phrase attributed to him, “that all things are full of Gods,”76 clearly meant that in his opinion the forces of
- 71. things inhered in the cosmos, and not in personal powers who spasmodically interfered with it.77 It is probable that, as was surmised by Plutarch, a pantheistic conception of Zeus existed for the Ionian Greeks before Thales.78 To the later doxographists he “seems to have lost belief in the Gods.”79 From the mere second-hand and often unintelligent statements which are all we have in his case, it is hard to make sure of his system; but that it was pantheistic80 and physicist seems clear. He conceived that matter not only came from but was resolvable into water; that all phenomena were ruled by law or “necessity”; and that the sun and planets (commonly regarded as deities) were bodies analogous to the earth, which he held to be spherical but “resting on water.”81 For the rest, he speculated in meteorology and in astronomy, and is credited with having predicted a solar eclipse 82—a fairly good proof of his knowledge of Chaldean science83— and with having introduced geometry into Greece from Egypt.84 To him, too, is ascribed a wise counsel to the Ionians in the matter of political federation,85 which, had it been followed, might have saved them from the Persian conquest; and he is one of the many early moralists who laid down the Golden Rule as the essence of the moral law.86 With his maxim, “Know thyself,” he seems to mark a broadly new departure in ancient thought: the balance of energy is shifted from myth and theosophy, prophecy and poesy, to analysis of consciousness and the cosmic process. From this point Greek rationalism is continuous, despite reactions, till the Roman conquest, Miletos figuring long as a general source of skepticism. Anaximandros (610–547 B.C.), pupil and companion of Thales, was like him an astronomer, geographer, and physicist, seeking for a first principle (for which he may or may not have invented the name87); rejecting the idea of a single primordial element such as water; affirming an infinite material cause, without beginning and indestructible,88 with an infinite number of worlds; and—still showing the Chaldean impulse—speculating remarkably on the descent of man from something aquatic, as well as on the form and motion of the earth (figured by him as a cylinder89), the nature and motions of the solar system, and thunder and lightning.90 It seems doubtful whether, as affirmed by Eudemus, he taught the doctrine of the earth’s motion; but
- 72. that this doctrine was derived from the Babylonian schools of astronomy is so probable that it may have been accepted in Miletos in his day. Only by inferring a prior scientific development of remarkable energy can we explain the striking force of the sayings of Anaximandros which have come down to us. His doctrine of evolution stands out for us to-day like the fragment of a great ruin, hinting obscurely of a line of active thinkers. The thesis that man must have descended from a different species because, “while other animals quickly found food for themselves, man alone requires a long period of suckling: had he been originally such as he is now, he could never have survived,” is a quite masterly anticipation of modern evolutionary science. We are left asking, how came an early Ionian Greek to think thus, outgoing the assimilative power of the later age of Aristotle? Only a long scientific evolution can readily account for it; and only in the Mesopotamian world could such an evolution have taken place.91 Anaximenes (fl. 548 B.C.), yet another Milesian, pupil or at least follower in turn of Anaximandros, speculates similarly, making his infinite and first principle the air, in which he conceives the earth to be suspended; theorizes on the rainbow, earthquakes, the nature and the revolution of the heavenly bodies (which, with the earth, he supposed to be broad and flat); and affirms the eternity of motion and the perishableness of the earth.92 The Ionian thought of the time seems thus to have been thoroughly absorbed in problems of natural origins, and only in that connection to have been concerned with the problems of religion. No dogma of divine creation blocked the way: the trouble was levity of hypothesis or assent. Thales, following a Semitic lead, places the source of all things in water. Anaximandros, perhaps following another, but seeking a more abstract idea, posited an infinite, the source of all things; and Anaximenes in turn reduces that infinite to the air, as being the least material of things. He cannot have anticipated the chemical conception of the reduction of all solids to gases: the thesis was framed either à priori or in adaptation of priestly claims for the deities of the elements; and others were to follow with the guesses of earth and fire and heat and cold. Still, the speculation is that of bold and far- grasping thinkers, and for these there can have been no validity in the ordinary God-ideas of polytheism.
- 73. There is reason to think that these early “schools” of thought were really constituted by men in some way banded together,93 thus supporting each other against the conservatism of religious ignorance. The physicians were so organized; the disciples of Pythagoras followed the same course; and in later Greece we shall find the different philosophic sects formed into societies or corporations. The first model was probably that of the priestly corporation; and in a world in which many cults were chronically disendowed it may well have been that the leisured old priesthoods, philosophizing as we have seen those of India and Egypt and Mesopotamia doing, played a primary part in initiating the work of rational secular thought. The recent work of Mr. F. M. Cornford, From Philosophy to Religion (1912), puts forth an interesting and ingenious theory to the effect that early Greek philosophy is a reduction to abstract terms of the practice of totemistic tribes. On this view, when the Gods are figured in Homer as subject to Moira (Destiny), there has taken place an impersonation of Nomos, or Law; and just as the divine cosmos or polity is a reflection of the earthly, so the established conception of the absolute compulsoriness of tribal law is translated into one of a Fate which overrules the Gods (p. 40 sq.). So, when Anaximandros posits the doctrine of four elements [he did not use the word, by the way; that comes later; see Burnet, ch. i, p. 56, citing Diels], “we observe that this type of cosmic structure corresponds to that of a totemic tribe containing four clans” (p. 62). On the other hand, the totemistic stage had long before been broken down. The “notion of the group-soul” had given rise to the notion of God (p. 90); and the primitive “magical group” had dissolved into a system of families (p. 93), with individual souls. On this prior accumulation of religious material early philosophy works (p. 138). It does not appear why, thus recognizing that totemism was at least a long way behind in Thales’s day, Mr. Cornford should trace the Ionian four elements straight back to the problematic four clans of the totemistic tribe. Dr. Frazer gives him no data whatever for Aryan totemism; and the Ionian cities, like those of Mesopotamia and Egypt, belong to the age of commerce and of monarchies. It would seem more plausible, on Mr. Cornford’s own premises, to trace the rival theories of the four elements to religious philosophies set up by the priests of four Gods of water, earth, air, and fire. If the early philosophers “had nothing but theology behind them” (p. 138), why not infer theologies for the old-established deities of Mesopotamia? Mr. Cornford adds to the traditional factors that of “the temperaments of the individual philosophers, which made one or other of those schemes the more congenial to them.” Following Dr. F. H. Bradley, he pronounces that “almost all philosophic arguments are invented afterwards, to recommend, or defend from attack, conclusions which the philosopher was from the outset bent on believing before he could think of any
- 74. arguments at all. That is why philosophical reasonings are so bad, so artificial, so unconvincing.” Upon this very principle it is much more likely that the philosophic cults of water, earth, air, and fire originated in the worships of Gods of those elements, whose priests would tend to magnify their office. It is hard to see how “temperament” could determine a man’s bias to an air-theory in preference to a water-theory. But if the priests of Ea the Water-God and those of Bel the God of Air had framed theories of the kind, it is conceivable that family or tribal ties and traditions might set men upon developing the theory quasi-philosophically when the alien Gods came to be recognized by thinking men as mere names for the elements.94 (Compare Flaubert’s Salammbô as to the probable rivalry of priests of the Sun and Moon.) A pantheistic view, again, arose as we saw among various priesthoods in the monarchies where syncretism arose out of political aggregations. What is clear is that the religious or theistic basis had ceased to exist for many educated Greeks in that environment. The old God-ideas have disappeared, and a quasi-scientific attitude has been taken up. It is apparently conditioned, perhaps fatally, by prior modes of thought; but it operates in disregard of so-called religious needs, and negates the normal religious conception of earthly government or providence. Nevertheless, it was not destined to lead to the rationalization of popular thought; and only in a small number of cases did the scientific thinkers deeply concern themselves with the enlightenment of the mass. In another Ionian thinker of that age, indeed, we find alongside of physical and philosophical speculation on the universe the most direct and explicit assault upon popular religion that ancient history preserves. Xenophanes of Kolophon (? 570–470), a contemporary of Anaximandros, was forced by a Persian invasion or by some revolution to leave his native city at the age of twenty-five; and by his own account his doctrines, and inferribly his life, had gone “up and down Greece”—in which we are to include Magna Graecia—for sixty-seven years at the date of writing of one of his poems.95 This was presumably composed at Elea (Hyela or Velia), founded about 536 B.C., on the western Italian coast, south of Paestum, by unsubduable Phokaians seeking a new home after the Persian conquest, and after they had been further defeated in the attempt to live as pirates in Corsica.96 Thither came the aged Xenophanes, perhaps also seeking freedom. He seems to have lived hitherto as a rhapsode, chanting his poems at the courts
- 75. of tyrants as the Homerids did the Iliad. It is hard indeed to conceive that his recitations included the anti-religious passages which have come down to us; but his resort in old age to the new community of Elea is itself a proof of a craving and a need for free conditions of life.97 Setting out on his travels, doubtless, with the Ionian predilection for a unitary philosophy, he had somewhere and somehow attained a pantheism which transcended the concern for a “first principle”—if, indeed, it was essentially distinct from the doctrine of Anaximandros.98 “Looking wistfully upon the whole heavens,” says Aristotle,99 “he affirms that unity is God.” From the scattered quotations which are all that remain of his lost poem, On Nature (or Natural Things),100 it is hard to deduce any full conception of his philosophy; but it is clear that it was monistic; and though most of his later interpreters have acclaimed him as the herald of monotheism, it is only in terms of pantheism that his various utterances can be reconciled. It is clearly in that sense that Aristotle and Plato101 commemorate him as the first of the Eleatic monists. Repeatedly he speaks of “the Gods” as well as of “God”; and he even inculcates the respectful worship of them.102 The solution seems to be that he thinks of the forces and phenomena of Nature in the early way as Gods or Powers, but resolves them in turn into a whole which includes all forms of power and intelligence, but is not to be conceived as either physically or mentally anthropomorphic. “His contemporaries would have been more likely to call Xenophanes an atheist than anything else.”103 The common verdict of the historians of philosophy, who find in Xenophanes an early and elevated doctrine of “Monotheism,” is closely tested by J. Freudenthal, Ueber die Theologie des Xenophanes, 1886. As he shows, the bulk of them (cited by him, pp. 2–7) do violence to Xenophanes’s language in making him out the proclaimer of a monotheistic doctrine to a polytheistic world. That he was essentially a pantheist is now recognized by a number of writers. Cp. Windelband, as cited, p. 48; Decharme, as cited, p. 46 sq. Bréton, Poésie philos. en Grèce, pp. 47, 64 sq., had maintained the point, against Cousin, in 1882, before Freudenthal. But Freudenthal in turn glosses part of the problem in ascribing to Xenophanes an acceptance of polytheism (cp. Burnet, p. 142), which kept him from molestation throughout his life; whereas Anaxagoras, who had never attacked popular belief with the directness of Xenophanes, was prosecuted for atheism. Anaxagoras was of a later age, dwelling in an Athens in which popular prejudice took readily to persecution, and
- 76. political malice resorted readily to religious pretences. Xenophanes could hardly have published with impunity in Periklean Athens his stinging impeachments of current God- ideas; and it remains problematic whether he ever proclaimed them in face of the multitude. It is only from long subsequent students that we get them as quotations from his poetry; there is no record of their effect on his contemporaries. That his God-idea was pantheistic is sufficiently established by his attacks on anthropomorphism, taken in connection with his doctrine of the All. Whether as teaching meant for public currency or as a philosophic message for the few, the pantheism of Xenophanes expressed itself in an attack on anthropomorphic religion, no less direct and much more ratiocinative than that of any Hebrew prophet upon idolatry. “Mortals,” he wrote, in a famous passage, “suppose that the Gods are born, and wear man’s clothing,104 and have voice and body. But if cattle or lions had hands, so as to paint with their hands and make works of art as men do, they would paint their Gods and give them bodies like their own—horses like horses, cattle like cattle.” And again: “Ethiopians make their Gods black and snub-nosed; the Thracians say theirs have reddish hair and blue eyes; so also they conceive the spirits of the Gods to be like themselves.”105 On Homer and Hesiod, the myth-singers, his attack is no less stringent: “They attributed to the Gods all things that with men are of ill-fame and blame; they told of them countless nefarious things—thefts, adulteries, and deception of each other.”106 It is recorded of him further that, like Epicurus, he absolutely rejected all divination.107 And when the Eleans, perhaps somewhat shaken by such criticism, asked him whether they should sacrifice and sing a dirge to Leukothea, the child-bereft Sea-Goddess, he bade them not to sing a dirge if they thought her divine, and not to sacrifice if she were human.108 Beside this ringing radicalism, not yet out of date, the physics of the Eleatic freethinker is less noticeable. His resort to earth as a material first principle was but another guess or disguised theosophy added to those of his predecessors, and has no philosophic congruity with his pantheism. It is interesting to find him reasoning from fossil-marks that what was now land had once been sea-covered, and been left mud; and that the moon is probably inhabited.109 Yet, with all this alertness of speculation, Xenophanes sounds the note of merely negative skepticism which, for lack
- 77. of fruitful scientific research, was to become more and more common in Greek thought:110 “no man,” he avows in one verse, “knows truly anything, and no man ever will.”111 More fruitful was his pantheism or pankosmism. “The All (οὖλος)” he declared, “sees, thinks, and hears.”112 “It was thus from Xenophanes that the doctrine of Pankosmism first obtained introduction into Greek philosophy, recognizing nothing real except the universe as an indivisible and unchangeable whole.”113 His negative skepticism might have guarded later Hellenes against baseless cosmogony- making if they had been capable of a systematic intellectual development. His sagacity, too, appears in his protest114 against that extravagant worship of the athlete which from first to last kept popular Greek life-philosophy unprogressive. But here least of all was he listened to. It is after a generation of such persistent questioning of Nature and custom by pioneer Greeks that we find in Herakleitos of Ephesus (fl. 500 B.C.)— still in the Ionian culture-sphere—a positive and unsparing criticism of the prevailing beliefs. No sage among the Ionians (who had already produced a series of powerful thinkers) left a deeper impression than he of massive force and piercing intensity: above all of the gnomic utterances of his age, his have the ring of character and the edge of personality; and the gossiping Diogenes, after setting out by calling him the most arrogant of men, concedes that the brevity and weight of his expression are not to be matched. It was due rather to this, probably, than to his metaphysic— though that has an arresting quality—that there grew up a school of Herakliteans calling themselves by his name. And though doubt attaches to some of his sayings, and even to his date, there can be small question that he was mordantly freethinking, though a man of royal descent. He has stern sayings about “bringing forth untrustworthy witnesses to confirm disputed points,” and about eyes and ears being “bad witnesses for men, when their souls lack understanding.”115 “What can be seen, heard, and learned, this I prize,” is one of his declarations; and he is credited with contemning book- learning as having failed to give wisdom to Hesiod, Pythagoras, Xenophanes, and Hekataios.116 The belief in progress, he roundly insists, stops progress.117 From his cryptic utterances it maybe gathered that he too was a pantheist;118 and from his insistence on the immanence of strife in all
- 78. things,119 as from others of his sayings, that he was of the Stoic mood. It was doubtless in resentment of immoral religion that he said120 Homer and Archilochos deserved flogging; as he is severe on the phallic worship of Dionysos,121 on the absurdity of prayer to images, and on popular pietism in general.122 One of his sayings, ἦθος ἀνθρώπῳ δαίμων,123 “character is a man’s dæmon,” seems to be the definite assertion of rationalism in affairs as against the creed of special providences. A confusion of tradition has arisen between the early Herakleitos, “the Obscure,” and the similarly-named writer of the first century of our era, who was either one Herakleides or one using the name of Herakleitos. As the later writer certainly allegorized Homer— reducing Apollo to the Sun, Athenê to Thought, and so on—and claimed thus to free him from the charge of impiety, it seems highly probable that it is from him that the scholiast on the Iliad, xv, 18, cites the passage scolding the atheists who attacked the Homeric myths. The theme and the tone do not belong to 500 B.C., when only the boldest—as Herakleitos —would be likely to attack Homer, and when there is no other literary trace of atheism. Grote, however (i, 374, note), cites the passages without comment as referring to the early philosopher, who is much more probably credited, as above, with denouncing Homer himself. Concerning the later Herakleitos or Herakleides, see Dr. Hatch’s Hibbert Lectures on The Influence of Greek Ideas and Usages upon the Christian Church, 1890, pp. 61, 62. But even apart from the confusion with the late Herakleides, there is difficulty in settling the period of the Ephesian thinker. Diogenes Laërtius states that he flourished about the 69th Olympiad (504–500 B.C.). Another account, preserved by Eusebius, places him in the 80th or 81st Olympiad, in the infancy of Sokrates, and for this date there are other grounds (Ueberweg, i, 40); but yet other evidences carry us back to the earlier. As Diogenes notes five writers of the name—two being poets, one a historian, and one a “serio-comic” personage—and there is record of many other men named Herakleitos and several Herakleides, there is considerable room for false attributions. The statement of Diogenes that the Ephesian was “wont to call opinion the sacred disease” (i, 6, § 7) is commonly relegated to the spurious sayings of Herakleitos, and it suggests the last mentioned of his namesakes. But see Max Müller, Hibbert Lectures on Indian Religion, p. 6, for the opinion that it is genuine, and that by “opinion” was meant “religion.” The saying, says Dr. Müller, “seems to me to have the massive, full, and noble ring of Herakleitos.” It is hardly for rationalists to demur. Much discussion has been set up by the common attribution to Herakleitos in antiquity of the doctrine of the ultimate conflagration of all things. But for this there is no ground in any actual passage preserved from his works; and it appears to have been a mere misconception of his doctrine in regard
- 79. to Fire. His monistic doctrine was, in brief, that all the opposing and contrasted things in the universe, heat and cold, day and night, evil and good, imply each other, and exist only in the relation of contrast; and he conceived fire as something in which opposites were solved.124 Upon this stroke of mysticism was concentrated the discussion which might usefully have been turned on his criticism of popular religion; his negative wisdom was substantially ignored, and his obscure speculation, treated as his main contribution to thought, was misunderstood and perverted. A limit was doubtless soon set to free speech even in Elea; and the Eleatic school after Xenophanes, in the hands of his pupil Parmenides (fl. 500 B.C.), Zeno (fl. 464), Melissos of Samos (fl. 444), and their successors, is found turning first to deep metaphysic and then to verbal dialectic, to discussion on being and not being, the impossibility of motion, and the trick-problem of Achilles and the tortoise. It is conceivable that thought took these lines because others were socially closed. Parmenides, a notably philosophic spirit (whom Plato, meeting him in youth, felt to have “an exceptionally wonderful depth of mind,” but regarded as a man to be feared as well as reverenced),125 made short work of the counter-sense of not being, but does not seem to have dealt at close quarters with popular creeds. Melissos, a man of action, who led a successful sally to capture the Athenian fleet,126 was apparently the most pronounced freethinker of the three named,127 in that he said of the Gods “there was no need to define them, since there was no knowledge of them.”128 Such utterance could not be carried far in any Greek community; and there lacked the spirit of patient research which might have fruitfully developed the notable hypothesis of Parmenides that the earth is spherical in form.129 But he too was a loose guesser, adding categories of fire and earth and heat and cold to the formative and material “principles” of his predecessors; and where he divagated weaker minds could not but lose themselves. From Melissos and Parmenides there is accordingly a rapid descent in philosophy to professional verbalism, popular life the while proceeding on the old levels. It was in this epoch of declining energy and declining freedom that there grew up the nugatory doctrine, associated with the Eleatic school,130 that
- 80. the only realities are mental,131 a formula which eluded at once the problems of Nature and the crudities of religion, and so made its fortune with the idle educated class. Meant to support the cause of reason, it was soon turned, as every slackly-held doctrine must be, to a different account. In the hands of Plato it developed into the doctrine of ideas, which in the later Christian world was to play so large a part, as “Realism,” in checking scientific thought; and in Greece it fatally fostered the indolent evasion of research in physics.132 Ultimately this made for supernaturalism, which had never been discarded by the main body even of rationalizing thinkers.133 Thus the geographer and historian Hekataios of Miletos (fl. 500 B.C.), living at the great centre of rationalism, while rejecting the mass of Greek fables as “ridiculous,” and proceeding in a fashion long popular to translate them into historical facts, yet affected, in the poetic Greek fashion, to be of divine descent.134 At the same time he held by such fables as that of the floating island in the Nile and that of the supernormal Hyperboreans. This blending of old and new habits of mind is indeed perhaps the strongest ground for affirming the genuineness of his fragments, which has been disputed.135 But from his time forward there are many signs of a broad movement of criticism, doubt, inquiry, and reconstruction, involving an extensive discussion of historical as well as religious tradition.136 There had begun, in short, for the rapidly-developing Greeks, a “discovery of man” such as is ascribed in later times to the age of the Italian Renaissance. In the next generation came the father of humanists, Herodotos, who implicitly carries the process of discrimination still further than did Hekataios; while Sophocles [496–405 B.C.], without ever challenging popular faith, whether implicitly as did Æschylus, or explicitly as did Euripides, “brought down the drama from the skies to the earth; and the drama still follows the course which Sophocles first marked out for it. It was on the Gods, the struggles of the Gods, and on destiny that Æschylus dwelt; it is with man that Sophocles is concerned.”137 Still, there was only to be a partial enlightenment of the race, such as we have seen occurring, perhaps about the same period, in India. Sophocles, even while dramatizing the cruel consequences of Greek religion, never made any sign of being delivered from the ordinary Greek conceptions of
- 81. deity, or gave any help to wiser thought. The social difference between Greece and the monarchic civilizations was after all only one of degree: there, as elsewhere, the social problem was finally unsolved; and the limits to Greek progress were soon approached. But the evolution went far in many places, and it is profoundly interesting to trace it. § 5 Compared with the early Milesians and with Xenophanes, the elusive Pythagoras (fl. 540–510 B.C.) is not so much a rationalistic as a theosophic freethinker; but to freethought his name belongs insofar as the system connected with it did rationalize, and discarded mythology. If the biographic data be in any degree trustworthy, it starts like Milesian speculation from oriental precedents.138 Pythagoras was of Samos in the Ægean; and the traditions have it that he was a pupil of Pherekydes the Syrian, and that before settling at Krôton, in Italy, he travelled in Egypt, and had intercourse with the Chaldean Magi. Some parts of the Pythagorean code of life, at least, point to an eastern derivation. The striking resemblance between the doctrine and practice of the Pythagoreans and those of the Jewish Essenes has led Zeller to argue (Philos. der Griechen, Th. iii, Abth. 2) that the latter were a branch of the former. Bishop Lightfoot, on the other hand, noting that the Essenes did not hold the specially prominent Pythagorean doctrines of numbers and of the transmigration of souls, traces Essenism to Zoroastrian influence (Ed. of Colossians, App. on the Essenes, pp. 150–51; rep. in Dissertations on the Apostolic Age, 1892, pp. 369–72). This raises the issue whether both Pythagoreanism and Essenism were not of Persian derivation; and Dr. Schürer (Jewish People in the Time of Jesus, Eng. tr. Div. II, vol. ii, p. 218) pronounces in favour of an oriental origin for both. The new connection between Persia and Ionia just at or before the time of Pythagoras (fl. 530 B.C.) squares with this view; but it is further to be noted that the phenomenon of monasticism, common to Pythagoreans and Essenes, arises in Buddhism about the Pythagorean period; and as it is hardly likely that Buddhism in the sixth century B.C. reached Asia Minor, there remains the possibility of some special diffusion of the new ideal from the Babylonian sphere after the conquest by Cyrus, there being no trace of a Persian monastic system. The resemblances to Orphicism likewise suggest a Babylonian source, as does the doctrine of
- 82. numbers, which is not Zoroastrian. As to Buddhism, the argument for a Buddhist origin of Essenism shortly before our era (cp. A. Lillie, Buddhism in Christendom and The Influence of Buddhism on Primitive Christianity; E. Bunsen, The Angel-Messiah; or, Buddhists, Essenes, and Christians—all three to be read with much caution) does not meet the case of the Pythagorean precedents for Essenism. Prof. Burnet (Early Greek Philos. 2nd ed. p. 102) notes close Indian parallels to Pythagoreanism, but overlooks the intermediate Persian parallels, and falls back very unnecessarily on the bald notion that “the two systems were independently evolved from the same primitive systems.” As regards the mystic doctrine that numbers are, as it were, the moving principle in the cosmos—another thesis not unlikely to arise in that Babylonian world whence came the whole system of numbers for the later ancients139—we can but pronounce it a development of thought in vacuo, and look further for the source of Pythagorean influence in the moral and social code of the movement, in its science, in its pantheism,140 its contradictory dualism,141 and perhaps in its doctrine of transmigration of souls. On the side of natural science, its absurdities142 point to the fatal lack of observation which so soon stopped progress in Greek physics and biology.143 Yet in the fields of astronomy, mathematics, and the science of sound the school seems to have done good scientific work; being indeed praised by the critical Aristotle for doing special service in that way.144 It is recorded that Philolaos, the successor of Pythagoras, was the first to teach openly (about 460 B.C.) the doctrine of the motion of the earth145—which, however, as above noted, was also said to have been previously taught by Anaximandros146 (from whom some incline to derive the Pythagorean theory of numbers in general147) and by Hiketas or Iketas (or Niketas) of Syracuse.148 Ekphantos, of that city, is also credited with asserting the revolution of the earth on its axis; and he too is grouped with the Pythagoreans, though he seems to have had a pantheism of his own.149 Philolaos in particular is said to have been prosecuted for his teaching,150 which for many was a blasphemy; and it may be that this was the reason of its being specially ascribed to him, though current in the East long before his day. In the fragments ascribed to him is affirmed, in divergence from other Pythagoreans, the eternity of the earth; and in other ways he seems to have been an innovator.151 In any case, the Pythagorean conception of the earth’s motion was a speculative one, wide of the facts, and not identical
- 83. with the modern doctrine, save insofar as Pythagoras—or Philolaos—had rightly conceived the earth as a sphere.152 It is noteworthy, however, that in conjecturing that the whole solar system moves round a “central fire,” Pythagoras carried his thought nearly as far as the moderns. The fanciful side of his system is seen in his hypothesis of a counter-earth (Anti-chthon) invented to bring up the number of celestial bodies in our system to ten, the “complete” number. (Berry, as cited.) Narrien (p. 163) misses this simple explanation of the idea. As to politics, finally, it seems hard to solve the anomaly that Pythagoras is pronounced the first teacher of the principle of community of goods,153 and that his adherents at Krôton formed an aristocratic league, so detested by the people for its anti-democratism that its members were finally massacred in their meeting-place, their leader, according to one tradition, being slain with them, while according to a better grounded account he had withdrawn and died at Metapontion. The solution seems to be that the early movement was in no way monastic or communistic; that it was, however, a secret society; that it set up a kind of puritanism or “methodism” which repelled conservative people; and that, whatever its doctrines, its members were mostly of the upper class.154 If they held by the general rejection of popular religion attributed to Pythagoras, they would so much the more exasperate the demos; for though at Krôton, as in the other Grecian colonial cities, there was considerable freedom of thought and speech, the populace can nowhere have been freethinking.155 In any case, it was after its political overthrow, and still more in the Italian revival of the second century B.C., that the mystic and superstitious features of Pythagoreanism were most multiplied; and doubtless the master’s teachings were often much perverted by his devotees. It was only too easy. He had laid down, as so many another moralist, that justice consisted in reciprocity; but he taught of virtue in terms of his theory of numbers156—a sure way of putting conduct out of touch with reality. Thus we find some of the later Pythagoreans laying it down as a canon that no story once fully current concerning the Gods was to be disbelieved157—the complete negation of philosophical freethought and a sharp contradiction of the other view which represented the shade of Pythagoras as saying that he had seen in Tartaros the shade of Homer hanged to a tree, and that of Hesiod chained to a pillar of brass, for the
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