Nursing Leadership Essay

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Nursing Leadership & Management





Sally A. Weiss , EdD, APRN, FNP-C, CNE, ANEF

Professor, Lead Faculty Graduate Program Herzing University

Menominee Falls, Wisconsin

Ruth M. Tappen , EdD, RN, FAAN Christine E. Lynn Eminent Scholar and Professor

Florida Atlantic University College of Nursing Boca Raton, Florida

Karen A. Grimley , PhD, MBA, RN, NEA-BC, FACHE

Chief Nursing Executive, UCLA Health Vice Dean, UCLA School of Nursing

Los Angeles, California



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To my granddaughter, Sydni, and my grandsons, Logan and Ian. Th eir curiosity and hunger for learning remind me how nurturing our novice nurses helps them in their quest to seek

new knowledge and continue their professional growth. —S ALLY A. W EISS

To students, colleagues, family, and friends, who have taught me so much about leadership.


To my kids, Kristina, Kathleen, Meagan, and Ian, for their love and understanding during this lifelong pursuit of learning.

To my dad for teaching me that the only limits we face are the ones we create and to my mom for instilling the value of a good

education. —K AREN A. G RIMLEY






We are pleased to bring our readers this seventh edition of Essentials of Nursing Leadership & Management. Th is new edition has been updated to refl ect the dynamic health-care environment, new safety and quality initiatives, and changes in the nursing practice environment. As in our previ- ous editions, the content, examples, and diagrams were designed with the goal of assisting the new graduate to make the transition to professional nursing practice.

Our readers may have noticed that we have added a new author to our team: Dr. Karen A. Grimley, Chief Nurse Executive at UCLA Health Center and Vice Dean of the School of Nursing at UCLA. We are delighted to have her join us, bringing a fresh perspective to this new edition.

Th e seventh edition of Essentials of Nursing Leadership & Management focuses on essential lead- ership and management skills and the knowledge needed by the staff nurse as a key member of the interprofessional health-care team and manager of patient care. Issues related to setting priorities, delegation, quality improvement, legal parameters of nursing practice, and ethical issues were also updated for this edition.

Th is edition discusses current quality and safety issues and the high demands placed on nurses in the current health-care environment. In addition, we continue to bring you comprehensive, practical information on developing a nursing career and addressing the many workplace issues that may arise in practice.

Th is new edition of Essentials of Nursing Leadership & Management will provide a strong foun- dation for the beginning nurse leader. We want to thank all of the people at F. A. Davis for their continued support and assistance in bringing this edition to fruition. We also want to thank our contributors, reviewers, colleagues, and students for their enthusiastic support. Th ank you all.









CANDACE JONES, BSN, MSN, RN Professor of Nursing

Greenville Technical College Greenville, South Carolina

SUSAN MUDD, MSN, RN, CNE Coordinator, Associate Degree Nursing Program

Elizabethtown Community & Technical College

Elizabethtown, Kentucky

DONNA WADE, RN, MSN Professor of Nursing

Mott Community College Flint, Michigan

JENNA L. BOOTHE, DNP, APRN, FNP-C Assistant Professor

Hazard Community and Technical College Hazard, Kentucky

LYNETTE DEBELLIS, MS, RN Chairperson and Assistant Professor of Nursing

Westchester Community College Valhalla, New York


Associate Professor of Nursing

Cleveland State Community College Cleveland, Tennessee






unit 1 Professionalism 1 chapter 1 Characteristics of a Profession 3 chapter 2 Professional Ethics and Values 13 chapter 3 Nursing Practice and the Law 35

unit 2 Leading and Managing 55 chapter 4 Leadership and Followership 57 chapter 5 Th e Nurse as Manager of Care 71 chapter 6 Delegation and Prioritization of Client Care Staffi ng 81 chapter 7 Communicating With Others and Working

With the Interprofessional Team 99 chapter 8 Resolving Problems and Confl icts 117

unit 3 Health-Care Organizations 131 chapter 9 Organizations, Power, and Professional

Empowerment 133 chapter 10 Organizations, People, and Change 149

chapter 11 Quality and Safety 163 chapter 12 Maintaining a Safe Work Environment 181 chapter 13 Promoting a Healthy Work Environment 197

unit 4 Your Nursing Career 213 chapter 14 Launching Your Career 215 chapter 15 Advancing Your Career 235

Table of Contents



xii Table of Contents

unit 5 Looking to the Future 249 chapter 16 What the Future Holds 251

Bibliography 263

Appendices appendix 1 Standards Published by the American Nurses Association 285 appendix 2 Guidelines for the Registered Nurse in Giving, Accepting,

or Rejecting a Work Assignment 287 appendix 3 National Council of State Boards of Nursing Guidelines

for Using Social Media Appropriately 293 appendix 4 Answers to NCLEX® Review Questions 295 Index 321



chapter 1 Characteristics of a Profession

chapter 2 Professional Ethics and Values

chapter 3 Nursing Practice and the Law

unit 1 Professionalism





OUTLINE Introduction

Professionalism Defi nition of a Profession Professional Behaviors

Evolution of Nursing as a Profession Nursing Defi ned

The National Council Licensure Examination Licensure Licensure by Endorsement Qualifi cations for Licensure Licensure by Examination


Political Infl uences and the Advance of Nursing Professionals

Nursing and Health-Care Reform

Nursing Today

The Future of Professional Nursing


OBJECTIVES After reading this chapter, the student should be able to: ■ Explain the qualities associated with a profession

■ Diff erentiate between a job, a vocation, and a profession

■ Discuss professional behaviors

■ Determine the characteristics associated with nursing as a profession

■ Explain licensure and certifi cation

■ Summarize the relationship between social change and the advancement of nursing as a profession

■ Discuss some of the issues faced by the nursing profession

■ Explain current changes impacting nursing ’ s future

chapter 1 Characteristics of a Profession



4 unit 1 ■ Professionalism


It is often said that you do not know where you are going until you know where you have been. More than 40 years ago, Beletz ( 1974 ) wrote that most people thought of nurses in gender- linked, task-oriented terms: “a female who per- forms unpleasant technical jobs and functions as an assistant to the physician” (p. 432). Interest- ingly, physicians in the 1800s viewed nursing as a complement to medicine. According to War- rington ( 1839 ), “. . . the prescriptions of the best physician are useless unless they be timely and properly administered and attended to by the nurse” (p. iv).

In its earliest years, most nursing care occurred at home. Even in 1791 when the fi rst hospital opened in Philadelphia, nurses continued to care for patients in their own home settings. It took almost another century before nursing moved into hospitals. Th ese institutions, mostly dominated by male physicians, promoted the idea that nurses acted as the “handmaidens” to the better-educated, more capable men in the medical fi eld.

Th e level of care diff ered greatly in these early health-care institutions. Th ose operated by the religious nursing orders gave high-quality care to patients. In others, care varied greatly from good to almost none at all. Although the image of nurses and nursing has advanced considerably since then, some still think of nurses as helpers who carry out the physician ’ s orders.

It comes as no surprise that nursing and health care have converged and reached a crossing point. Nurses face a new age for human experience; the very foundations of health practices and thera- peutic interventions continue to be dramatically altered by signifi cantly transformed scientifi c, technological, cultural, political, and social realities ( Porter-O’Grady , 2003 ). Th e global environment needs nurses more than ever to meet the health- care needs of all.

Nursing sees itself as a profession rather than a job or vocation and continues with this quest for its place among the health-care disciplines. However, what defi nes a profession? What behaviors are expected from the members of the profession? Chapter 1 discusses nursing as a profession with its own identity and place within this new and ever-changing health-care system.


Defi nition of a Profession A vocation or calling defi nes “meaningful work” depending on an individual ’ s point of view ( Dik & Duff y, 2009 ). Nursing started as a vocation or “calling.” Until Nightingale, most nursing occurred through religious orders. To care for the ill and infi rmed was a duty ( Kalisch & Kalisch, 2004 ). In early years, despite the education required, nursing was considered a job or vocation ( Cardillo, 2013 ).

Providing a defi nition for a “profession” or “pro- fessional” is not as easy as it appears. Th e term is used all the time; however, what characteristics defi ne a professional? According to Saks ( 2012 ), several theoretical approaches have been applied to creating a defi nition of a profession, the older of these looking only at knowledge and expertise, whereas later ones include a code of ethics, prac- tice standards, licensure, and certifi cation, as well as expected behaviors ( Post, 2014 ).

Nurses engage in specialized education and training confi rmed by successfully passing the National Council Licensure Examination (NCLEX®) and receiving a license to practice in each state. Nurses follow a code of ethics and recognized practice standards and a body of con- tinuous research that forms and directs our practice. Nurses function autonomously within the desig- nated scope of practice, formulating and delivering a plan of care for clients, applying judgments, and utilizing critical thinking skills in decision making ( Cardillo, 2013 ).

Professional Behaviors According to Post ( 2014 ), professional characteris- tics or behaviors include:

■ Consideration ■ Empathy ■ Respect ■ Ethical and moral values ■ Accountability ■ Commitment to lifelong learning ■ Honesty

Professionalism denotes a commitment to carry out specialized responsibilities and observe ethical principles while remaining responsive to diverse recipients ( Al-Rubaish, 2010 ). Communicating



chapter 1 ■ Characteristics of a Profession 5

eff ectively and courteously within the work envi- ronment is expected professional behavior. State boards of nursing through the nurse practice acts elaborate expected behaviors in a registered nurse ’ s professional practice and personal life (National Council of State Boards of Nursing [ NCSBN], 2012, 2016 ). Nurses may lose their licenses for a variety of actions deemed unprofessional or illegal. For example, inappropriate use of social media, posting emotionally charged statements in blogs or forums, driving without a license, and committing felonies outside of professional practice may be cause for suspending or revoking a nursing license.

Commitment to others remains central to a profession. In nursing, this entails commitment to colleagues, lifelong learning, and accountability for one ’ s actions. Professionalism in the workplace means coming to work when scheduled and on time. Coming to work late shows disrespect to your peers and colleagues. It also indicates to your super- visor that this position is not important to you.

Always portray a positive attitude. Although everyone experiences a bad day, projecting personal feelings and issues onto others aff ects the work environment. Many agencies and institutions have dress codes. Dress appropriately per the employ- er ’ s expectations. Wearing heavy makeup, colognes, or inappropriate hairstyles demonstrates a lack of professionalism. Finally, always speak profession- ally to everyone in the work environment. A good rule to follow should be, “If you wouldn ’ t say it in front of your grandmother, do not say it in the workplace” ( McKay, 2017 ).

Work politics often create an unfavorable envi- ronment. Stay away from gossip or engaging in negative comments about others in the workplace. Change the topic or indicate a lack of interest in this type of verbal exchange. Negativity is conta- gious and aff ects workplace morale. Professionals maintain a positive attitude in the work environ- ment. If the environment aff ects this attitude, it is time to look for another position ( McKay, 2017 ).

Lastly, professional behavior entails honesty and accountability. If a day off is needed, take a personal or vacation day; save sick days for illness. Own up to errors. In nursing, an error may result in injury or death. Th e health-care environment should promote a culture of safety, not one of pun- ishment for errors. Th is is discussed more in later chapters.

Evolution of Nursing as a Profession

Nursing Defi ned Th e changes that have occurred in nursing are refl ected in the defi nitions of nursing that have developed through time. In 1859, Florence Night- ingale defi ned the goal of nursing as putting the client “in the best possible condition for nature to act upon him” ( Nightingale, 1992/1859 , p. 79). In 1966, Virginia Henderson focused her defi nition on the uniqueness of nursing:

Th e unique function of the nurse is to assist the individual, sick or well, in the performance of those

activities contributing to health or its recovery (or

to peaceful death) that he would perform unaided

if he had the necessary strength, will or knowledge.

And to do this in such a way as to help him gain

independence as rapidly as possible. ( Henderson, 1966 , p. 21)

Martha Rogers defi ned nursing practice as “the process by which this body of knowledge, nursing science, is used for the purpose of assisting human beings to achieve maximum health within the potential of each person” ( Rogers, 1988 , p. 100). Rogers emphasized that nursing is concerned with all people, only some of whom are ill.

In the modern nursing era, nurses are viewed as collaborative members of the health-care team. Nursing has emerged as a strong fi eld of its own in which nurses have a wide range of obligations, responsibilities, and accountability. Recent polls show that nurses are considered the most trusted group of professionals because of their knowl- edge, expertise, and ability to care for diverse populations.

Nightingale ’ s concepts of nursing care became the basis of modern theory development, and in today ’ s language, she used evidence-based prac- tice to promote nursing. Her 1859 book Notes on Nursing: What It Is and What It Is Not laid the foun- dation for modern nursing education and practice. Many nursing theorists have used Nightingale ’ s thoughts as a basis for constructing their view of nursing.

Nightingale believed that schools of nursing must be independent institutions and that women who were selected to attend the schools should be



6 unit 1 ■ Professionalism

from the higher levels of society. Many of Night- ingale ’ s beliefs about nursing education are still applicable, particularly those involved with the progress of students, the use of diaries kept by students, and the need for integrating theory into clinical practice ( Roberts, 1937 ).

Th e Nightingale school served as a model for nursing education. Its graduates were sought worldwide. Many of them established schools and became matrons (superintendents) in hospitals in other parts of England, the British Common- wealth, and the United States. However, very few schools were able to remain fi nancially indepen- dent of the hospitals and thus lost much of their autonomy. Th is was in contradiction to Nightin- gale ’ s philosophy that the training schools were educational institutions, not part of any service agency.

The National Council Licensure Examination

Professions require advanced education and an advanced area of knowledge and training. Many are regulated in some way and have a licensure or certifi cation requirement to enter practice. Th is holds true for teachers, attorneys, physicians, and pilots, just to name a few. Th e purpose of a profes- sional license is to ensure public safety, by setting a level of standard that indicates an individual has acquired the necessary knowledge and skills to enter into the profession.

Licensure Licensure for nurses is defi ned by the NCSBN as the process by which boards of nursing grant permission to an individual to engage in nursing practice after determining that the applicant has attained the competency necessary to perform a unique scope of practice. Licensure is necessary when the regulated activities are complex, require specialized knowledge and skill, and involve independent decision making ( NCSBN, 2012 ). Government agencies grant licenses allowing an individual to engage in a professional practice and use a specifi c title. State boards of nursing issue nursing licenses. Th is limits practice to a specifi c jurisdiction. However, as the NCLEX® is a nation- ally recognized examination, many states have joined together to form a “compact” where the

license in one state is recognized in another. States belonging to the compact passed legislation adopt- ing the terms of the agreement. Th e state in which the nurse resides is considered the home state, and license renewal occurs in the home state ( NCSBN , 2018a ).

Licensure may be mandatory or permissive. Permissive licensure is a voluntary arrangement whereby an individual chooses to become licensed to demonstrate competence. However, the license is not required to practice. In this situation a manda- tory license is not required to practice. Mandatory licensure requires a nurse to be licensed in order to practice. In the United States and Canada, licen- sure is mandatory.

Licensure by Endorsement If a state is not a member of the compact, nurses licensed in one state may obtain a license in another state through the process of endorsement. Each application is considered independently and is granted a license based on the rules and regula- tions of the state.

States diff er in the number of continuing edu- cation credits required, mandatory courses, and other educational requirements. Some states may require that nurses meet the current criteria for licensure at the time of application, whereas others may grant the license based on the criteria in eff ect at the time of the original license. When applying for a license through endorsement, a nurse should always contact the board of nursing for the state and ask about the exact requirements for licensure in that state. Th is information is usually found on the state board of nursing Web site.

NURSYS is a national database that houses information on licensed nurses. Nurses apply- ing for licensure by endorsement may verify their licenses through this database. Th e nurse ’ s license verifi cation is available immediately to the endors- ing board of nursing ( NCSBN , 2016 ). Not all states belong to NURSYS.

Qualifi cations for Licensure Th e basic qualifi cation for licensure requires graduation from an approved nursing program. In the United States, each state may add additional requirements, such as disclosures regarding health or medications that could aff ect practice. Most states require disclosure of criminal conviction.



chapter 1 ■ Characteristics of a Profession 7

Licensure by Examination A major accomplishment in the history of nursing licensure was the creation of the Bureau of State Boards of Nurse Examiners. Th e formation of this agency led to the development of an identical examination in all states. Th e original examination, called the State Board Test Pool Examination, was created by the testing department of the National League for Nursing (NLN). Th is was completed through a collaborative contract with the state boards. Initially, each state determined its own passing score; however, the states did eventually adopt a common passing score. Th e examination is called the NCLEX-RN ® and is used in all states and territories of the United States. Th is test is prepared and administered through a professional testing company.


Th e NCLEX-RN ® is administered through com- puterized adaptive testing (CAT). Candidates need to register to take the examination at an approved testing center in the state in which they intend to practice. Because of a large test bank, CAT permits a variety of questions to be adminis- tered to a group of candidates. Candidates taking the examination at the same time may not neces- sarily receive the same questions. Once a candidate answers a question, the computer analyzes the response and then chooses an appropriate question to ask next. If the candidate answers the question correctly, the following question may be more dif- fi cult; if the candidate answers incorrectly, the next question may be easier.

In April 2016, the NCSBN released the updated test plan. Th e new test plan redistributed the percentages for each content area and updated the question format with increased use of technol- ogy that better simulated patient care situations. More updated information on the NCLEX® test plans may be found on the NCSBN Web site ( ).

Political Infl uences and the Advance of Nursing Professionals

Nursing made many advances during the time of social upheaval and change. Th e passing of the Social Security Act in 1935 strengthened public

health services. Public health nursing found itself in an ideal position to step up and assume respon- sibility for providing care to dependent mothers and children, the blind, and disabled children ( Black, 2014 ). In 1965, under President Lyndon B. Johnson, amendments to the Social Security Act designed to ensure access to health care for the elder adult, the poor, and the disabled resulted in the creation of Medicare and Medicaid (Centers for Medicare and Medicaid Services [ CMS ], 2017 ). Health insurance companies emerged and increased in number during this time as well. Hos- pitals started to rely on Medicare, Medicaid, and insurance reimbursement for services. Care for the sick and new opportunities and roles emerged for nurses within this environment.

Historically, as a profession, nursing has made most of its advances during times of social change. Th e 1960s through the 1980s brought many changes for both women and nursing. In 1964, President Johnson signed the Civil Rights Act, which guaranteed equal treatment for all individ- uals and prohibited gender discrimination in the workplace. However, the law lacked enforcement. During this time, the feminist movement gained momentum, and the National Organization for Women was founded to help women achieve equality and give women a voice. Nursing moved forward as well. Specialty care disciplines devel- oped. Advances in technology gave way to the more complex medical–surgical treatments such as cardiothoracic surgery, complex neurosurgical techniques, and the emergence of intensive care environments to care for these patients. Th ese changes fostered the development of specializa- tion for nurses and physicians, creating a shortage of primary care physicians. Th e public demanded increased access to health care, and nursing again stepped forward by developing an advanced prac- tice role for nurses to meet the primary health-care needs of the public.

Th roughout the years, wars created situations that facilitated changes in nursing and its role within society. Wars increased the nation ’ s need for nurses and the public ’ s awareness of nursing ’ s role in society ( Kalisch & Kalisch, 2004 ). Nurses served in the military during both world wars and the Korean confl ict and changed nursing practice during the time of war. For the fi rst time, nurses were close to the front and worked in mobile hos- pital units. Often they lacked necessary supplies



8 unit 1 ■ Professionalism

and equipment ( Kalisch & Kalisch, 2004 ). Th ey found themselves in situations where they needed to function independently and make immediate decisions, often assuming roles normally associated with the physicians and surgeons.

Th e Vietnam War aff orded nurses opportunities to push beyond the boundaries as they functioned in mobile hospital units in the war theater, often without direct supervision of physicians. Th ese nurses performed emergency procedures such as tracheostomies and chest tube insertions in order to preserve the lives of the wounded soldiers ( Texas Tech University, 2017 ). After functioning inde- pendently in the fi eld, many nurses felt restricted by the practice limits placed on them when they returned home.

Challenges for society and nurses continued from the 1980s through 2000. Th e 1980s were marked by the emergence of the HIV virus and AIDS. Although we know more about HIV and AIDs today than we knew more than 30 years ago, society ’ s fear of the disease stigmatized groups of individuals and created fear among global popu- lations and health-care providers. Nurses became instrumental in educating the public and working directly with infected individuals.

Th e increase in available technology allowed for the widespread use of life-support systems. Nurses working in critical care areas often faced ethical dilemmas involving the use of these tech- nologies. During this time period, nurses voiced their opinions and concerns and helped in formu- lating policies addressing these issues within their communities and institutions. Th e fi eld of hospice nursing received a renewed interest and support (National Hospice and Palliative Care Organi- zation [ NHPCO ], 2012 ); therefore, the number of hospice care providers grew and opened new opportunities for nurses.

Th e fi rst part of the 21st century introduced nurses to situations beyond anyone ’ s imagina- tion. Nursing ’ s response to the terrorist attack on the World Trade Center and during the onset and aftermath of Hurricane Katrina raised mul- tiple questions regarding nurses’ abilities to react to major disasters. Nurses, physicians, and other health-care providers attempted to care for and protect patients under horrifi c conditions. Nurses found themselves trying to function “during unfa- miliar and unusual conditions with the health care environment that may necessitate adaptations

to recognized standards of nursing practice” (American Nurses Association [ ANA ], 2006 ).

Nursing has recognized the need for the profession to understand and function during human-caused and natural disasters such as 9/11 and hurricanes. Th e profession has answered the call by increasing disaster preparedness training for nurses.

Nursing and Health-Care Reform

For more than 40 years, Florence Nightingale played an infl uential part in most of the important health-care reforms of her time. Her accomplish- ments went beyond the scope of nursing and nursing education, aff ecting all aspects of health care and social reform.

Nightingale contributed to health-care reform through her work during the Crimean War, where she greatly improved the health and well-being of the British soldiers. She kept accurate records and accountings of her interventions and outcomes, and on her return to England she continued this work and reformed the conditions in hospitals and health care.

Th e 21st century brings both challenges and opportunities for nursing. It is estimated that more than 434,000 nurses will be needed by the year 2024 (Bureau of Labor Statistics [ BLS ], 2017 ). Th e severe nursing shortage has increased the demand for more nurses, whereas the passing of the Aff ordable Care Act (ACA) off ers oppor- tunities for nurses to take the lead in providing primary health care to those who need it. More advanced practice nurses will be needed to address the needs of the diverse population in this country. Health-care reform is discussed in more detail in Chapter 16 .

Nursing Today

Issues specifi c to nursing refl ect the problems and concerns of the health-care system as a whole. Th e average age of nurses in the United States is 46.8 years, and approximately 50% of the nursing workforce is older than 50 ( NCSBN, 2015 ). Because of changes in the economy, many nurses who planned to retire have instead found it nec- essary to remain in the workforce. However, the recent data collected also noted an increase in men



chapter 1 ■ Characteristics of a Profession 9

entering the fi eld as well as an increase in younger and more diverse populations seeking nursing careers.

Concerns about the supply of registered nurses (RNs) and staffi ng shortages persist in both the United States and abroad. For the fi rst time, multi- ple generations of nurses fi nd themselves working together within the health-care environment. Th e oldest of the generations, the early baby boomers, planned to retire during the last several years; however, economics have forced many to remain in the workplace. Th ey presently work alongside Generation X (born between 1965 and 1979) and the generation known as the millennials (born in 1980 and later). Nurses from the baby boomer generation and Generation X provide the major- ity of bedside care. Where the millennials fi nd themselves comfortable with technology, the baby boomers feel the “old ways” worked well.

Generational issues in the nursing workforce present potential confl icts in the work environ- ment as these generations come with diff ering viewpoints as they attempt to work together within the health-care community ( Bragg, 2014 ; Moore, Everly, & Bauer, 2016 ). Each generation brings its own set of core values to the workplace. In order to be successful and work together as cohesive teams, each generation needs to value the others’ skills and perspectives. Th is requires active and assertive communication, recognizing the individual skill sets of the generations, and placing individuals in positions that fi t their specifi c characteristics.

Th e related issues of excessive workload, man- datory overtime, scheduling, abuse, workplace violence, and lack of professional autonomy con- tribute to the concerns regarding the nursing shortage ( Clarke, 2015 ; Wheatley, 2017 ). Th ese issues impact the workplace environment and often place patients at risk. Professional behavior requires respect and integrity, as well as safe practice.

The Future of Professional Nursing

Th e changes in health care and the increased need for primary care providers has opened the door for nursing. Th e Institute of Medicine (IOM , 2010 ) report specifi cally stated that nurses should be permitted to practice to the full extent of their education. Nurses are educated to care for individ- uals who have chronic illnesses and need health teaching and monitoring.

Advanced practice nurses (APRNs) are qual- ifi ed to diagnose and treat certain conditions. Th ese highly educated nurses are more than phy- sician extenders as they sit for board certifi cation examinations and are licensed by the states in which they practice. Educational requirements for APRNs include a minimum of a master ’ s degree in nursing with a clinical focus, and a designated number of clinical hours. Many nurse practition- ers are obtaining the Doctor of Nursing Practice (DNP) degree. Th e American Association of Crit- ical Care Nurses (AACN) and the NLN both promote this as the terminal degree for nurse practitioners. Areas of advanced practice include family nurse practitioner, acute care nurse prac- titioner, pediatric nurse practitioner, and certifi ed nurse midwife.


Professional behavior is an important component of nursing practice. It is outlined and guided by state nurse practice acts, the ethical codes, and standards of practice. Acting professionally both while in the workplace and in one ’ s personal life is also an expectation. As nursing moves forward in the 21st century, the need for committed profes- sionals and innovative nurse leaders is greater than ever. Society ’ s demand for high-quality health care at an aff ordable cost is now law and an impetus for change in how nurses function in the new environment.

Employers, colleagues, and peers depend on new nurses to act professionally and provide safe, quality patient care. Taking advantage of expand- ing educational opportunities, engaging in lifelong learning, and seeking certifi cation in a specialty demonstrate professional commitment.

Nursing has its roots as a calling and vocation. It originated in the community, moved to hospi- tals, returned to the community, and is now seen in multiple practice settings. Th e ACA has opened doors for more opportunities for nurses, and the IOM report on the Future of Nursing states that nurses need to be permitted to use their educa- tional skills in the health-care environment.

Often students ask the question: “So what can I do? I am a new graduate.” Get involved in your profession by joining organizations and becoming politically active. Continue pursuing excellence and set the stage for those who will come after you.



10 unit 1 ■ Professionalism

Study Questions

1. Read Notes on Nursing: What It Is and What It Is Not by Florence Nightingale. How much of its content is still true today?

2. What is your defi nition of nursing? How does it compare or contrast with Virginia Henderson ’ s defi nition?

3. Review the mission and purpose of the ANA or another national nursing organization online. Do you believe that nurses should belong to these organizations? Explain your answer.

4. Professional behaviors include a commitment to lifelong learning. What does “lifelong learning” mean beyond mandatory continuing education?

5. Formulate your plan to prepare for the NCLEX®.

Case Studies to Promote Critical Reasoning

Case I Th omas went to nursing school on a U.S. Public Health Service scholarship. He has been directed to go to a rural village in a small Central American country to work in a local health center. Several other nurses have been sent to this village, and the residents forced them to leave.

Th e village lacks electricity and plumbing; water comes from in-ground wells. Th e villagers and children suff er from frequent episodes of gastrointestinal disorders.

1. How do you think Florence Nightingale would have approached these issues?

2. What do you think Th omas should do fi rst to gain the trust of the residents of the village?

3. Explain how APRNs would contribute to the health and welfare of the residents of the village.

Case II Th e younger nurses in your health-care institution have created a petition to change the dress code policy. Th ey feel it is antiquated and rigid. Rather than wearing uniforms or scrubs on the nursing units, they would prefer to wear more contemporary clothing such as khakis and nice shirts with the agency logo along with laboratory coats. Th e older-generation nurses feel that this will detract from the nursing image, as patients expect nurses to dress in uniforms or scrubs and this is what defi nes them as a “profession.”

1. What are your thoughts regarding the image of nursing and uniforms?

2. Do you feel that uniforms defi ne nurses? Explain your reasoning.

3. Explain the reasons certain generations may see this as a threat to their professionalism.

4. Which side would you support? Explain your answer with current research.



chapter 1 ■ Characteristics of a Profession 11

NCLEX®-Style Review Questions

1. Nursing has its origins with 1. Florence Nightingale 2. Th e Knights of Columbus 3. Religious orders 4. Wars and battles

2. Who stated that the “function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death)”? 1. Henderson 2. Rogers 3. Robb 4. Nightingale

3. You are participating in a clinical care coordination conference for a patient with terminal cancer. You talk with your colleagues about using the nursing code of ethics for professional registered nurses to guide care decisions. A non-nursing colleague asks about this code. Which of the following statements best describes this code? 1. Improves communication between the nurse and the patient 2. Protects the patient ’ s right of autonomy 3. Ensures identical care to all patients 4. Acts as a guide for professional behaviors in giving patient care

4. Th e NCLEX® for nurses is exactly the same in every state in the United States. Th e examination: 1. Guarantees safe nursing care for all patients 2. Ensures standard nursing care for all patients 3. Ensures that honest and ethical care is provided 4. Provides a minimal standard of knowledge for a registered nurse in practice

5. APRNs generally: Select all that apply. 1. Function independently 2. Function as unit directors 3. Work in acute care settings 4. Work in the university setting 5. Hold advanced degrees

6. Nurses at a community hospital are in an education program to learn how to use a new pressure-relieving device for patients at risk for pressure ulcers. Th is is which type of education? 1. Continuing education 2. Graduate education 3. In-service education 4. Professional registered nurse education

7. Which of the following is unique to a professional standard of decision making? Select all that apply. 1. Weighs benefi ts and risks when making a decision 2. Analyzes and examines choices more independently 3. Concrete thinking 4. Anticipates when to make choices without others’ assistance



12 unit 1 ■ Professionalism

8. Nursing practice in the 21st century is an art and science that focuses on: 1. Th e client 2. Th e nursing process 3. Cultural diversity 4. Th e health-care facility

9. Which of the following represent the knowledge and skills expected of the professional nurse? Select all that apply. 1. Accountability 2. Advocacy 3. Autonomy 4. Social networking 5. Participation in nursing blogs

10. Professional accountability serves the following purpose: Select all that apply. 1. To provide a basis for ethical decision making 2. To respect the decision of the client 3. To maintain standards of health 4. To evaluate new professional practices and reassess existing ones 5. To belong to a professional organization.




OUTLINE Values Morals Values and Moral Reasoning Value Systems How Values Are Developed Values Clarifi cation

Belief Systems

Ethics and Morals Ethics Ethical Theories Ethical Principles

Autonomy Nonmalefi cence Benefi cence Justice Fidelity Confi dentiality Veracity Accountability

Ethical Codes Virtue Ethics Nursing Ethics Organizational Ethics Ethical Issues on the Nursing Unit Moral Distress in Nursing Practice Ethical Dilemmas

Resolving Ethical Dilemmas Faced by Nurses Assessment Planning Implementation Evaluation Current Ethical Issues Practice Issues Related to Technology

Technology and Treatment Technology and Genetics

DNA Use and Protection Stem Cell Use and Research Professional Dilemmas


OBJECTIVES After reading this chapter, the student should be able to: ■ Discuss ways individuals form values

■ Diff erentiate between laws and ethics

■ Explain the relationship between personal ethics and professional ethics

■ Examine various ethical theories

■ Explore the concept of virtue ethics

■ Apply ethical principles to an ethical issue

■ Evaluate the infl uence organizational ethics exerts on nursing practice

■ Identify an ethical dilemma in the clinical setting

■ Discuss current ethical issues in health care and possible solutions

chapter 2 Professional Ethics and Values



14 unit 1 ■ Professionalism

Doctors at the Massachusetts General Hospital for Children faced an ethical challenge when a pair of conjoined twins born in Africa arrived last year seeking surgery that could save only one of them. Th e twins were connected at the abdomen and pelvis, sharing a liver and bladder, and had three legs. An examination by doctors at the hospital determined that only one of the girls was likely to survive the surgery, but that if doctors did not act, both would die. Th e case had posed the hospital with the challenge both of ensuring that the parents understood the risks of the procedure and that the hundreds of medical professionals needed to perform the complex series of operations to separate the children were comfortable with the ethics of the situation ( Malone, 2017 ). Which child should live, and which child should die?

“iron lung”). During this period, Danish physi- cians invented a method of manual ventilation by placing a tube into the trachea of polio patients. Th is initiated the creation of mechanical venti- lation as we know it today. Th e development of mechanical ventilation required more intensive nursing care and patient observation. Th e care and monitoring of patients proved to be more effi cient when nurses kept patients in a single care area, hence the term intensive care.

Th e late 1960s brought greater technological advances. Open heart surgery, in its infancy at the time, became available for patients who were seri- ously ill with cardiovascular disease. Th ese patients required specialized nursing care and nurses specifi cally educated in the use of advancing tech- nologies. Th ese new therapies and monitoring methods provided the impetus for the creation of intensive care units and the critical care nursing specialty ( Vincent, 2013 ).

In the past, the vast majority of individuals receiving critical care services would have died. However, the development of new drugs and advances in biomechanical technology permit health-care personnel to challenge nature. Th ese advances have enabled providers to off er patients treatments that in many cases increase their life expectancy and enhance their quality of life. However, this progress is not without its shortcom- ings as it also presents new perplexing questions.

Th e ability to prolong life has created some heart-wrenching situations for families and complex ethical dilemmas for health-care pro- fessionals. Decisions regarding terminating life support on an adolescent involved in a motor vehicle accident, instituting life support on a 65-year-old productive father, or a mother becom- ing pregnant in order to provide stem cells for her older child who has a terminally ill disease are just a few examples. At what point do parents say good-bye to their neonate who was born far too early to survive outside the womb? Families and professionals face some of the most diffi cult ethical decisions at times such as these. How is death defi ned? When does it occur? Perhaps these questions need to be asked: “What is life? Is there a diff erence between life and living?”

To fi nd answers to these questions, health-care professionals look to philosophy, especially the branch that deals with human behavior. Th rough time, to assist in dealing with these issues, the fi eld

Th is is only one of many modern ethical dilem- mas faced by health-care personnel. If you were a member of the ethics committee, what decision might you make? How would you come to that decision? Which twin would live and which would die?

In previous centuries, health-care practitioners had neither the knowledge nor the technology to make determinations regarding prolonging life, sustaining life, or even creating life. Th e main function of nurses and physicians was to support patients and families through times of illness, help them toward recovery, or provide comfort until death. Th ere were very few complicated decisions such as “Who shall live and who shall die?” During the latter part of the 20th century and through the fi rst part of the 21st century, technological advances such as multiple-organ transplantation, use of stem cells, new biologically based pharmaceuticals, and sophisticated life-support systems created unique situations stimulating serious conversations and debates. Th e costs of these life-saving treatments and technologies presented new dilemmas as to who should provide and pay for them, as well as who should receive them.

Health care saw its fi rst technological advances during 1947 and 1948 as the polio epidemic raged through Europe and the United States. Th is dev- astating disease initiated the development of units for patients who required manual ventilation (the



chapter 2 ■ Professional Ethics and Values 15

of biomedical ethics (or simply bioethics) evolved. Th is subdiscipline of ethics, the philosophical study of morality, is the study of medical morality, which concerns the moral and social implications of health care and science in human life ( Nummi- nen, Repo, & Leino-Kilpi, 2017 ).

In order to understand biomedical ethics, it is important to appreciate the basic concepts of values, belief systems, ethical theories, and morality. Th e following sections will defi ne these concepts and then discuss ways nurses can help the interprofessional team and families resolve ethical dilemmas.


Individuals talk about value and values all the time. Th e term value refers to the worth of an object or thing. However, the term values refers to how individuals feel about ideas, situations, and concepts. Merriam-Webster’s Collegiate Dictio- nary defi nes value as the “estimated or appraised worth of something, or that quality of a thing that makes it more or less desirable, useful” ( Merriam- Webster Dictionary, 2017 ). Values, then, are judg- ments about the importance or unimportance of objects, ideas, attitudes, and attributes. Individuals incorporate values as part of their conscience and worldview. Values provide a frame of reference and act as pilots to guide behaviors and assist people in making choices.

Morals Morals arise from an individual ’ s conscience. Th ey act as a guide for individual behavior and are learned through family systems, instruction, and socialization. Morals fi nd their basis within indi- vidual values and have a larger social component than values ( Ma, 2013 ). Th ey focus more on “good” versus “bad” behaviors. For example, if you value fairness and integrity, then your morals include those values, and you judge others based on your concept of morality ( Maxwell & Narvaez, 2013 ).

Values and Moral Reasoning Reasoning is the process of making inferences from a body of information and entails forming conclusions, making judgments, or making inferences from knowledge for the purpose of answering questions, solving problems, and formu- lating a plan that determines actions ( McHugh &

Way, 2018 ). Reasoning allows individuals to think for themselves and not to take the beliefs and judgments of others at face value. Moral reasoning relates to the process of forming conclusions and creating action plans centered on moral or ethical issues.

Values, viewpoints, and methods of moral reasoning have developed through time. Older worldviews have now emerged in modern history, such as the emphasis on virtue ethics or a focus on what type of person one would prefer to become ( McLeod-Sordjan, 2014 ). Virtue ethics are dis- cussed later in this chapter.

Value Systems A value system is a set of related values. For example, one person may value (believe to be important) societal aspects of life, such as money, objects, and status. Another person may value more abstract concepts such as kindness, charity, and caring. Values may vary signifi cantly, based on an individual ’ s culture, family teachings, and reli- gious upbringing. An individual ’ s system of values frequently aff ects how he or she makes decisions. For example, one person may base a decision on cost, whereas another person placed in the same situation may base the decision on a more abstract quality, such as kindness. Values fall into diff erent categories:

■ Intrinsic values are those related to sustaining life, such as food and water ( Zimmerman & Zalta, 2014 ).

■ Extrinsic values are not essential to life. Th ey include the value of objects, both physical and abstract. Extrinsic values are not an end in themselves but off er a means of achieving something else. Th ings, people, and material items are extrinsically valuable ( Zimmerman & Zalta, 2014 ).

■ Personal values are qualities that people consider important in their private lives. Concepts such as strong family ties and acceptance by others are personal values.

■ Professional values are qualities considered important by a professional group. Autonomy, integrity, and commitment are examples of professional values.

People ’ s behaviors are motivated by values. Indi- viduals take risks, relinquish their own comfort and security, and generate extraordinary eff orts



16 unit 1 ■ Professionalism

because of their values ( Zimmerman & Zalta, 2014 ). Patients who have traumatic brain injuries may overcome tremendous barriers because they value independence. Race car drivers may risk death or other serious injury because they value competition and winning.

Values also generate the standards by which people judge others. For example, someone who values work more than leisure activities will look unfavorably on a coworker who refuses to work throughout the weekend. A person who believes that health is more important than wealth would approve of spending money on a relaxing vacation or perhaps joining a health club rather than invest- ing the money.

Often people adopt the values of individu- als they admire. For example, a nursing student may begin to value humor after observing it used eff ectively with patients. Values provide a guide for decision making and give additional meaning to life. Individuals develop a sense of satisfaction when they work toward achieving values they believe are important ( Tuckett, 2015 ).

How Values Are Developed Values are learned ( Taylor, 2012 ). Ethicists attri- bute the basic question of whether values are taught, inherited, or passed on by some other mechanism to Plato, who lived more than 2,000 years ago. A recent theory suggests that values and moral knowledge are acquired much in the same manner as other forms of knowledge, through real-world experience.

Values can be taught directly, incorporated through societal norms, and modeled through behavior. Children learn by watching their parents, friends, teachers, and religious leaders. Th rough continuous reinforcement, children eventually learn about and then adopt values as their own. Because of the values they hold dear, people often make great demands on themselves and others, ignoring the personal cost. For example:

Values change with experience and maturity. For example, young children often value objects, such as a favorite blanket or toy. Older children are more likely to value a specifi c event, such as a family vacation. As children enter adolescence, they place more value on peer opinions than those of their parents. Young adults often place value on certain ideals such as heroism. Th e values of adults are formed from all these experiences as well as from learning and thought.

Th e number of values that people hold is not as important as what values they consider important. Choices are infl uenced by values. Th e way people use their own time and money, choose friends, and pursue a career are all infl uenced by values.

Values Clarifi cation Values clarifi cation is deciding what one believes is important. It is the process that helps people become aware of their values. Values play an important role in everyday decision making. For this reason, nurses need to be aware of what they do and do not value. Th is process helps them to behave in a manner that is consistent with their values.

Both personal and professional values infl u- ence nurses’ decisions ( McLeod-Sordjan, 2014 ). Understanding one ’ s own values simplifi es solving problems, making decisions, and developing better relationships with others when one begins to realize how others develop their values. Kirschen- baum ( 2011 ) suggested using a three-step model of choosing, prizing, and acting with seven sub- steps to identify one ’ s own values ( Box 2-1 ).

You may have used this method when making the decision to go to nursing school. For some people, nursing is a fi rst career; for others, a second career. Using the model in Box 2-1 , the valuing process is analyzed:

Niesa grew up in a family where educational achievement was highly valued. Not surpris- ingly, she adopted this as one of her own values. Niesa became a physician, married, and had a son, Dino. She placed a great deal of eff ort on teaching her son the necessary educational

skills in order to get him into the “best private school” in the area. As he moved through the program, his grades did not refl ect his mother ’ s great eff ort, and he felt that he had disap- pointed his mother as well as himself. By the time Dino reached 9 years of age, he had devel- oped a variety of somatic complaints such as stomach ailments and headaches.



chapter 2 ■ Professional Ethics and Values 17

1. Choosing After researching alternative career options, you freely choose nursing school. Th is choice was most likely infl uenced by such factors as educational achievement and abilities, fi nances, support and encouragement from others, time, and feelings about people.

2. Prizing Once the choice was made, you were satisfi ed with it and told your friends about it.

3. Acting You entered school and started the journey toward your new career. Later in your career, you may decide to return to school for a bachelor ’ s or master ’ s degree in nursing.

As you progressed through school, you proba- bly started to develop a new set of values—your professional values. Professional values are those established as being important in your practice. Th e values include caring, quality of care, and ethical behaviors ( McLeod-Sordjan, 2014 ).

Belief Systems

Belief systems are an organized way of think- ing about why people exist in the universe. Th e purpose of belief systems is to explain issues such as life and death, good and evil, and health and illness. Usually these systems include an ethical code that specifi es appropriate behaviors. People may have a personal belief system, participate in a religion that provides such a system, or follow a combination of the two.

Members of primitive societies worshipped events in nature. Unable to understand the science

of weather, for example, early civilizations believed these events to be under the control of someone or something that needed to be appeased. Th ere- fore, they developed rituals and ceremonies to pacify these unknown entities. Th ey called these entities “gods” and believed that certain behaviors either pleased or angered the gods. Because these societies associated certain behaviors with specifi c outcomes, they created a belief system that enabled them to function as a group.

As higher civilizations evolved, belief systems became more complex. Archeology has provided evidence of the religious practices of ancient civ- ilizations that support the evolution of belief systems ( Ball, 2015 ). Th e Aztec, Mayan, Incan, and Polynesian cultures had a religious belief system composed of many gods and goddesses for the same functions. Th e Greek, Roman, Egyptian, and Scandinavian societies believed in a hierarchal system of gods and goddesses. Although given various names by the diff erent cultures, it is very interesting that most of the deities had similar purposes. For example, the Greeks looked at Zeus as the king of the Greek gods, whereas Jupiter was his Roman counterpart. Th or was the king of the Norse gods. All three used a thunderbolt as their symbol. Sociologists believe that these religions developed to explain what was then unexplainable. Human beings have a deep need to create order from chaos and to have logical explanations for events. Religion off ers theological explanations to answer questions that cannot be explained by “pure science.”

Along with the creation of rites and rituals, reli- gions also developed codes of behaviors or ethical codes. Th ese codes contribute to the social order and provide rules regarding how to treat family members, neighbors, and the young and the old. Many religions also developed rules regarding marriage, sexual practices, business practices, prop- erty ownership, and inheritance.

For some individuals, the advancement of science has minimized their need for belief systems, as science can now provide explanations for many previously unexplainable phenomena. In fact, the technology explosion has created an even greater need for belief systems. Technologi- cal advances often place people in situations where they may welcome rather than oppose religious convictions to guide diffi cult decisions. Many reli- gions, particularly Christianity, focus on the will of

box 2-1

Values Clarifi cation Choosing 1. Choosing freely 2. Choosing from alternatives 3. Deciding after giving consideration to the

consequences of each alternative

Prizing 4. Being satisfi ed about the choice 5. Being willing to declare the choice to others

Acting 6. Making the choice a part of one ’ s worldview and

incorporating it into behavior 7. Repeating the choice

Source: Adapted from Raths, L. E., Harmon, M., & Simmons, S. B. (1979). Values and teaching. New York, NY: Charles E. Merrill.



18 unit 1 ■ Professionalism

a supreme being; technology, for example, is con- sidered a gift that allows health-care personnel to maintain the life of a loved one. Other religions, such as certain branches of Judaism, focus on free choice or free will, leaving such decisions in the hands of humankind. For example, many Jewish leaders believe that if genetic testing indicates that an infant will be born with a disease such as Tay-Sachs that causes severe suff ering and ulti- mately death, terminating the pregnancy may be an acceptable option.

Belief systems often help survivors in making decisions and living with them afterward. So far, technological advances have created more ques- tions than answers. As science explains more and more previously unexplainable phenomena, people need beliefs and values to guide their use of this new knowledge.

Ethics and Morals

Although the terms morals and ethics are often used interchangeably, ethics usually refers to a standard- ized code as a guide to behaviors, whereas morals usually refers to an individual ’ s personal code for acceptable behavior.

Ethics Ethics is the part of philosophy that deals with the rightness or wrongness of human behavior. It is also concerned with the motives behind that behavior. Bioethics , specifi cally, is the application of ethics to issues that pertain to life and death. Th e implication is that judgments can be made about the rightness or goodness of health-care practices.

Ethical Theories Several ethical theories have emerged to justify moral principles ( Baumane-Vitolina, Cals, & Sumilo, 2016 ). Deontological theories take their norms and rules from the duties that individuals owe each other by the goodness of the commit- ments they make and the roles they take upon themselves. Th e term deontological comes from the Greek word deon (duty). Th is theory is attributed to the 18th-century philosopher Immanuel Kant ( Kant, 1949 ). Deontological ethics considers the intention of the action. In other words, it is the individual ’ s good intentions or goodwill ( Kant, 1949 ) that determines the worthiness or goodness of the action.


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