Nsg 2113: Introduction to Nursing Science

Nursing Roles and The Image of Nurses

Wendy Gifford, RN, PhD(c)

Class Objectives
To identify the educational preparation and skills required to work in nursing roles.

To explain the roles and responsibilities of nurses (RNs, RPNs APNs).

To examine the image of nurses and the nursing profession. To identify factors that contribute to the public and self images of nurses.

Education

Early Education
1860: Florence Nightingale established SON in association with Hospital London, England 1874: First hospital diploma SON in Canada
St. Catharine's General and Marine Hospital Admission standards: Plain English education, good character, and Christian motives nursing considered undesirable vocation refined ladies
What was the 1 acceptable vocation?

University Programs
WWI & 1918 Influenza pandemic led to support for public health programs and new patterns of health care delivery Nurses were seen as central participants who needed university level education Canadian Red Cross: awarded grants to # of universities to develop public health nursing 1919: 1st nursing degree University of British Columbia 1975: proposed by 1995 entry to practice be baccalaureate degree (Alberta Task Force on Nursing Education)
Radical proposal at time / requirement now in most provinces

1991: Doctoral Nursing program University of Alberta

Education Levels in Nursing

(CNA, 2008)
2000
Diploma 75.6% 175,801 64%

2006
162,493

Bacc
Masters Doctorate Total RNs

22.7%
1.6% 0.1%

52,927
3,652 186

33%
2.5% 0.15%

83,704
6,354 382

232,566

252,933

Registered Nurses in Canada

What does it means?

Definition of Registered Nurse

(CNA, 2007) Registered nurses are self-regulated health-care professionals who work autonomously and in collaboration with others. RNs enable individuals, families, groups, communities and populations to achieve their optimal level of health. RNs coordinate health care, deliver direct services and support clients in their self-care decisions and actions in situations of health, illness, injury and disability in all stages of life

What does it mean to be selfregulated health care professionals?

Registered nurses are self-regulated health-care professionals who work autonomously and in collaboration with others.

Self-Regulation: Legislative requirement

Regulated Health Professions Act (1991)

each regulatory college to develop, establish and maintain programs to promote continuing competence among members of the profession. College of Nurses of Ontario (CNO)

College of Nurses of Ontario (CNO)

Regulatory body for the provinces 150,000 nurses. Works to protect the public interest by supporting nurses in their practice. To be legally entitled to practise nursing and use the protected titles of nurse, RN, RPN, NP
Certificate of Registration College membership

Every member is responsible for practising in accordance with the standards of the profession, and for keeping current and competent throughout their nursing career.

Compendium of Standards of Practice for Nurses in Ontario (CNO Third Edition)

everything a practising nurse needs to know about regulation of the nursing profession in Ontario. Four sections:
Introduction (role of college, Am I practicing nursing?) Practice Standards Practice Guidelines Legislation and Regulation

http://www.cno.org/pubs/compendium.html#intro

Four key regulatory functions of CNO

1. Articulate and promote practice standards.
expectations that contribute to public protection. inform nurses of accountabilities and inform public of what to expect of nurses. assures public and employers that individuals who enter nursing profession have the necessary knowledge, skill and judgment to provide safe care.

2. Establish requirements for entry to practice.

3. Administer Quality Assurance (QA) Program.

legislative requirement. supports nurses s to practise according to standards and continually improve. facilitates practice development in areas that need
members of the public have the opportunity to express concerns about the nursing care they have received. College responds in a number of ways, including disciplinary measures for professional misconduct.

4. Enforce standards of practice and conduct.

CNO: Quality Assurance (QA) Program

Regulated Health Professions Act (RHPA, 1991) requires that the College establish and operate a QA program that assists nurses maintain competence...

1. Self-Assessment (all members)

evaluating strengths / areas to improve developing and maintaining a learning plan

2. Practice Assessment (random selection)

objective review Submit learning plan for peer assessment / complete test.

3. Peer Assessment
College-assigned Assessors review Practice Assessment Make recommendations to QA Committee/ may require members to complete additional learning activities.

Professional Roles & Responsibilities

The Practice of Nursing

Nursing Act (1991)
The practice of nursing is the promotion of health, and the assessment of, the provision of, care for, and the treatment of, health conditions, by supportive, preventative, therapeutic, palliative, and rehabilitative means in order to attain or maintain optimal function. Authorizes nurses to perform three controlled acts:
1. 2. 3. performing a prescribed procedure below the dermis or mucous membrane; administering a substance by injection or inhalation; putting an instrument, hand or finger beyond the: external ear canal, nasal passages, larynx, opening of the urethra, labia majora, anal verge, or into an artificial opening in the body.

RNs in health-care
Direct clinical practice Education Administration Research Policy

Theoretical Constructs concerned with: Person Health Nursing Environment

(CNA, 2007)

Discussion Questions

What brought you into nursing? What characteristics or roles come to mind when you think of a nurse?

Advanced Practice Nurses (APNs)

Advanced Practice Nurses (APNs)

Registered nurses who have acquired expert knowledge base, complex decision-making skills, & clinical competencies for expanded practice (ICN 2005) APN role dimensions:
Direct patient care Consultation/collaboration Education Research Leadership/change agents
(CHSRF & CIHR)

2001: Canada research chair for APN

Types of APN Roles

(Hamric et al, 2005)

Clinical Nurse Specialist (CNS) Nurse Practitioner (NP) Nurse Anaesthetist* Nurse-midwife*
* Roles in USA only Initial work underway to introduce Nurse anaesthetists in Canada

Effectiveness of APNs
Numerous randomized controlled trials (RCTs) and systematic reviews have shown that APNs are effective, safe practitioners who can positively influence patient, provider and health system outcomes:

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Clinical Nurse Specialists (CNSs)

Introduced in early 1970s Prepared at graduate level Numbers reduced in early 1990s as result of hospital funding cutbacks Resurgence of role

Clinical Nurse Specialists (CNSs)

Specialize in clinical practice
may be defined in terms of a population, a setting, a disease or medical subspecialty, type of care, etc
address complex health care issues for patients, families, other disciplines, administrators, and policy makers

Domains of Practice
Expert clinical practice Consultation Education Research Leadership
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Nurse Practitioners
Introduced in 1960s
Legislation exists in all Canadian provinces & territories Involved in health promotion, disease prevention & acute and chronic illness management

Nurse Practitioners (NPs)

Scope of Practice (CNA, 2002)
Diagnose Prescribe medications Prescribe treatment Refer clients to other professionals Admit patients to hospital

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NPs .... Examples

Ontario Family Health Team
introduced in 2005 150 teams in 2009 Requirement is that each must have at least 1 NP

Sudbury, Ontario
first of 25 NP-led clinics is up and running

Cost-Effectiveness of NP Role
(CNA, 2003)

80-90% of visits to primary care physicians can be managed by NPs NPs cost 40% less than physicians NPs are cost-effective in terms of preventive care because of expertise in counselling, patient/client education, and case management

Advanced Practice Nursing Workforce by Province in 2008

NA NA 52 99

<10

2 5 3 46 29 872

88 663

210 303

98

*
80 49 2 5 4 8

63

115

555
415

Canadian NP Total = 1,626

Canadian CNS Total = 2,222

Source: Regulated Nursing Database, Canadian Institute for Health Information

Consider the following

About half of all physicians are specialists and half are family

physicians. If 5 % of all nurses (about 14,000) begin to

provide primary care, this 5% could replace up to 40% of the family physicians (Sutherland, 1996).

Registered Practical Nurses (RPNs)

RPNs
In Ontario nursing is one profession with two categories:
Registered Nurse (RN) Registered Practical Nurse (RPN)

overlap exists in certain client care tasks critical practice differences exist RPN Education
2 year practical nursing diploma RPNs RNs 3 years

RN versus RPN
RN draws on more in-depth theoretical and clinical knowledge
Have greater range of care delivery options from which to select when adopting a plan of care

carry out broader, more in-depth assessment,

expected to be able to analyze and synthesize client data to a much greater extent than an RPN.

RN is prepared to address high risk, complex, unpredictable client care needs.

RNs / RPNs
Client Risk Category Low risk
RPNs and RNs independently care for clients Predictable

Medium-risk

High-risk

RPNs and RN collaborate RNs care independently; at varying degrees in care RPNs may be involved in limited aspects of care Moderately predictable Unpredictable

Less complex Low risk of negative outcomes

Moderately complex More Complex Moderate risk of negative High risk of negative outcomes outcome

Utilization of RNs and RPNs practice guideline (CNO, 2009) http://www.cno.org/docs/prac/41062_UtilizeRnRpn.pdf

Image of Nurses/Nursing

Image of nurses in the media

(Kalisch & Kalisch,1982) Researchers surveyed print media & non-print media
200 novels 143 magazine short stories, poems, articles 20,000 newspaper clippings 204 motion pictures, 122 radio programs and 320 television episodes

classified the nursing image into 5 time periods......

Image of nurses in the media

1. 1854-1919 2. 1920-1929 3. 1930-1945 4. 1945-1965 Angel of Mercy Girl Friday The Heroine The Mother Image

5. 1965- 1982

Sex Object

Gender of Employed RNs

(CNA, 2006) Female: 94.4% (n= 238,665) Male: 5.6% (n= 14,283)
41 % Quebec 28% Ontario 10% British Columbia 7% Alberta

Gender Stereotyping in Nursing

(Evans, 2002; 2004)

What is the image of men as nurses?

What are the benefits to the nursing profession to encourage men to consider nursing as a career?

Nursing Self-Image
(Buresh & Gordon, 2000) Influenced through socialization process (society & profession) Self-image reflected though:
personal appearance interactions with other nurses other health care providers the public

To end the silence nurses need to:

Inform the public about nursing Make public communication and education about nursing an integral part of her or his nursing work Communicate in ways that highlight nurses knowledge rather than their virtues

What does a nurse really do?

This note was left at a nurse's station at a rehabilitation unit in Detroit by a difficult patient upon his discharge. (reproduced largely verbatim)

Dear [Nurse],
I wanted to thank you personally for teaching this old dog new tricks. I always thought that nurses were basically the doctor's handmaidens..... that the sexy little stereotype portrayed on television... was correct. I looked upon your profession badly, and I sincerely apologize. What I have found during my stay in your care is a completely different story .... I think each patient should be given a copy of this on admission, and hospitals should be known as nursing care providers, because a patient enters the hospital for nursing care. I found this out during my stay. I had nurses 24 hours a day every day I was hospitalized, I had maybe 10 minutes a day with the doctor. So here goes my opinion of what every patient needs to know.

1. 2.

You have been placed in the hospital for nursing care. The provider of that care is an educated individual who unselfishly dedicates themselves to your health and well-being. And even though you may not like being told what things are good for you and what are not, the nurse telling you does so to give you a chance to redeem your health and well-being. That provider is proud to be a nurse.

3.

4.

That nurse does more than you know. She plans your care around your medical condition, emotional state, abilities to do for yourself (sorry, [nurse], I think you said "self care" in your rant), that nurse provides support to you and your family, she/he is the link between you and the doctor, [and] everything in the facility.
That nurse does your bedside care, she knows what medicine you need when, and how to give it. She knows what all the tubes and stuff are and what they are used for and what to look at them for.

5.

6.

That nurse can hang an IV or hold your hand and reassure you.

7.

That nurse watches over you and reads monitors and knows when [you're] sleeping and when [you're] awake and pulls strings to get you that cup of tea at 3 a.m.
That nurse is your lifeline, she can call a whole team of professionals together with her calm voice and make them work their [butts] off for your life with the flash of her/his eyes. That nurse will wish you luck and give you all the instructions you need when you leave her competent care even if you were the biggest pain in the [butt] she ever met.

8.

9.

10. The nurse is why you are in the hospital and why you will go onward, be it home, perpetual care, or the morgue. She will insure that you do so with your dignity and rights intact. Why? Because it is what a nurse does. signed/ .................

Center for Nursing Advocacy www.nursingadvocacy.org

Discussion Question
What is your image of nurses in 2010 Why should nurses be concerned about their public image?

References
Buresh, B., & Gordon, S. (2000). From silence to voice: What nurses know and must communicate to the public. Ottawa: Canadian Nurses Association. Canadian Nurses Association. (2006) 2006 workforce profile of Registered Nurses in Canada. Ottawa: Author. CNA (2002). Fact sheet: Role of the nurse practitioner around the world. Ottawa: Author. CNA (2003). Position Statement: Cost-effectiveness of the nurse practitioner role. Ottawa: Author CNA (2003). Position Statement: Clinical nurse specialist. Ottawa: Author Evans, J. A. (2002). Cautious caregivers: Gender stereotypes and the sexualization of men nurses touch. Journal of Advanced Nursing, 40(4), 441-448.

References
Evans, J. A. (2004). Men nurses: A historical and feminist perspective. Journal of Advanced Nursing, 47(3), 321- 328. Hamric, A. B., Spross, J.A., & Hanson, C. M. (2005). Advanced Practice Nursing. St Louis: Elsevier Saunders. Higuchi, K. S., Hagen, B., Brown, S., & Zeiber, M. P. (2006). Meeting the needs of rural seniors: A new role for advanced practice nurses in Canada. Journal of Gerontological Nursing, 32(7), 49-55. Davies, B. & Hughes, A. M. (2002). Clarification of advanced nursing practice: Characteristics and competencies. Clinical Nurse Specialist, 16 (3), 147-152.

Sutherland, R. (1996). Will nurses call the shots? Ottawa: Canadian Nurses Association.

References
Kalisch, B. & Kalisch, P. (1982) Anatomy of the image of the nurse: Dissonant and ideal models. In C. Williams (Ed.) Image Making in Nursing (pp. 3-23) Kansas City: American Academy of Nursing. Lusk, B. (2000). Pretty and powerless: Nurses in advertisements, 19301950. Research in Nursing and Health, 23, 229-236.

Wood, M. J. & MacPhail, J. (2003). The professional image: Impact and strategies for change. In J. C. Ross-Kerr & M. J. Wood (Eds.),
Canadian Nursing: Issues and Perspectives (4th ed., pp. 65-81). Toronto: Elsevier Science Canada.