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As students are involved in the clinical and academic environments we believe that ethical principles are a necessary guide to profes- sional development. Therefore within these environments we:

1. Advocate for the rights of all clients.

2. Maintain client confidentiality.

3. Take appropriate action to ensure the safety of clients, self, and others.

4. Provide care for the client in a timely, compassionate, and professional manner.

5. Communicate client care in a truthful, timely, and accurate manner.

6. Actively promote the highest level of moral and ethical principles and accept responsibility for our actions.

7. Promote excellence in nursing by encouraging lifelong learning and professional development.

8. Treat others with respect and promote an environment that respects human rights, values, and choice of cultural and spiritual beliefs.

9. Collaborate in every reasonable manner with the academic faculty and clinical staff to ensure the highest quality of client care.

10. Use every opportunity to improve faculty and clinical staff understanding of the learning needs of nursing students.

11. Encourage faculty, clinical staff, and peers to mentor nursing students.

12. Refrain from performing any technique or procedure for which the student has not been adequately trained.

13. Refrain from any deliberate action or omission of care in the academic or clinical setting that creates unnecessary risk of injury to the client, self, or others.

14. Assist the staff nurse or preceptor in ensuring that there is full disclosure and that proper authorizations are obtained from clients regarding any form of treatment or research.

15. Abstain from the use of alcoholic beverages or any substances in the academic and clinical setting that impair judgment.

16. Strive to achieve and maintain an optimal level of personal health.

17. Support access to treatment and rehabilitation for students who are experiencing impairments related to substance abuse and mental or physical health issues.

18. Uphold school policies and regulations related to academic and clinical performance, reserving the right to challenge and critique rules and regulations as per school grievance policy.

Adopted by the NSNA House of Delegates, Nashville, TN, on April 6, 2001. Reprinted with permission.

entire health care system, and nursing, as a major component of that system, cannot avoid the effects.

Health Care Reform With the passage of the Affordable Care Act (ACA) in 2010, health care reform was on a fast track. Transformation in health care deliv- ery and financing systems accelerated in 2014 when major provisions of the legislation were implemented (Buerhaus et al., 2012, p. 318). Health care delivery’s focus has shifted from acute care to primary preventive care and treatment of chronic conditions using health care teams and information technology. Also in 2010, an IOM report, The Future of Nursing: Leading Change, Advancing Health, provided rec- ommendations on what nursing needed to do to provide better cli- ent care in the new systems that would be part of health reform. This report identified four key areas: nurses practicing to the fullest extent of their skills and knowledge; nurses achieving higher levels of educa- tion; nurses being full partners with physicians and other health care professionals; and improving data collection and an information in- frastructure (IOM, 2010, p. 4).

Quality and Safety in Health Care Quality and safety are inherent universal values on which health care is based (Sherwood, 2011, p. 227). However, the report To Err is Human, published by the IOM in 2000 revealed a gap between the status of American health care and the quality Americans should re- ceive. Since then, the IOM has published a series of reports confirm- ing that “quality and safety are the leading contemporary issues in health care, contributing to costs and poor outcomes” (Sherwood & Barnsteiner, 2012, p. 3). The 2003 IOM report, Health Professions Ed- ucation: A Bridge to Quality, called for a redesign of the education for health care professions and described six core competencies needed to improve 21st-century health care: patient- centered care, team- work and collaboration, evidence-based practice, quality improve- ment, safety, and informatics. In 2005, the Robert Wood Johnson Foundation funded a project called Quality and Safety Education for Nurses (QSEN). The goal for the QSEN project was to “meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work” (QSEN Institute, n.d.). This project used the IOM six competencies along with the knowledge and experiences of QSEN faculty and a national advisory board to define quality and safety competencies for nursing. The project also proposed KSAs for each competency that could be used as guides for curriculum development in preli- censure nursing programs (see the table at the QSEN website).

Consumer Demands Consumers of nursing services (the public) have become an increas- ingly effective force in changing nursing practice. On the whole, peo- ple are better educated and have more knowledge about health and illness than in the past. Consumers also have become more aware of others’ needs for care. The ethical and moral issues raised by poverty and neglect have made people more vocal about the needs of minor- ity groups and the poor.

The public’s concepts of health and nursing have also changed. Most now believe that health is a right of all people, not just a privilege

of the rich. The media emphasize the message that individuals must assume responsibility for their own health by obtaining a physical examination regularly, checking for the seven danger signals of can- cer, and maintaining their mental well-being by balancing work and recreation. Interest in health and nursing services is therefore greater than ever. Furthermore, many people now want more than freedom from disease—they want energy, vitality, and a feeling of wellness.

Increasingly, the consumer has become an active participant in making decisions about health and nursing care. Planning com- mittees concerned with providing nursing services to a community usually have active consumer membership. Recognizing the legiti- macy of public input, many state nursing associations and regula- tory agencies have consumer representatives on their governing boards.

Family Structure New family structures are influencing the need for and provision of nursing services. More people are living away from the extended family and the nuclear family, and the family breadwinner is no lon- ger necessarily the husband. Today, many single men and women rear children, and in many two-parent families both parents work. It is also common for young parents to live at great distances from their own parents. These young families need support services, such as day care centers. For additional information about the family, see Chapter 24 .

Adolescent mothers also need specialized nursing services, both while they are pregnant and after their babies are born. These young mothers usually have the normal needs of teenagers as well as those of new mothers. Many teenage mothers are raising their children alone with little, if any, assistance from the child’s father. This type of single-parent family is especially vulnerable because motherhood compounds the difficulties of adolescence. Also, because many of these families live in poverty, the children often do not receive pre- ventive immunizations and are at increased risk for nutritional and other health problems.

Science and Technology Advances in science and technology affect nursing practice. For ex- ample, people with acquired immunodeficiency syndrome (AIDS) are receiving new drug therapies to prolong life and delay the on- set of AIDS-associated diseases. Nurses must be knowledgeable about the action of such drugs and the needs of clients receiving them. Biotechnology is affecting health care. For example, nurses are exposed to emerging genetic technology such as the field of can- cer gene therapy (Parsons, 2011). Nurses will need to expand their knowledge base and technical skills as they adapt to meet the new needs of clients.

In some settings, technologic advances have required that nurses be highly specialized. Nurses frequently have to use sophisticated computerized equipment to monitor or treat clients. As technologies change, nursing education changes, and nurses require increasing education to provide effective, safe nursing practice.

The space program has developed advanced technologies for space travel based on the need for long-distance monitoring of astro- nauts and spacecraft, lighter materials, and miniaturization of equip- ment. Health care has benefited as this new technology has been

oversight of a nurse practitioner’s practice; however 16 states still require NPs to practice under severe restrictions (Selway, 2012, p. 11). As a result, NPs cannot easily move from state to state, which decreases access to care for clients. In 2008, 48 professional organi- zations, including the NCSBN developed a Consensus Model that provides guidance for states to adopt uniformity in the regulation of advanced practice registered nurses. Many states have adopted portions of the model elements, but variations remain from state to state (NCSBN, 2013).

Demography Demography is the study of population, including statistics about distribution by age and place of residence, mortality (death), and morbidity (incidence of disease). From demographic data, the needs of the population for nursing services can be assessed. For example:

• The total population in North America is increasing. The propor- tion of older adults has also increased, creating an increased need for nursing services for this group.

• The population is shifting from rural to urban settings. This shift signals an increased need for nursing related to problems caused by pollution and by the effects on the environment of concentra- tions of people. Thus, most nursing services are now provided in urban settings.

• Mortality and morbidity studies reveal the presence of risk factors. Many of these risk factors (e.g., smoking) are major causes of death and disease that can be prevented through changes in lifestyle. The nurse’s role in assessing risk factors and helping clients make healthy lifestyle changes is discussed in Chapter 16 .

The Current Nursing Shortage Registered nurses are the largest segment of the health care workforce. According to the Bureau of Labor Statistics (2013), the number of em- ployed RNs will grow from 2.7 million in 2012 to 3.2 million in 2022; this number increases by an additional 1.2 million when including replacements for nurses who leave or retire from the profession. Contrast that information with an AACN statement (2012b) that the United States is projected to have a nursing shortage that is expected to intensify as baby boomers age and the need for health care grows. Factors for this prediction include the concurrent nursing faculty shortage, the increasing average age of RNs, and the increasing num- ber of aging older adults along with their increasing health care needs.

Whereas there is a projected shortage of nurses by 2022, whether or not there is a current nursing shortage depends on where the nurses live and where they are willing to work. The supply and demand of nurses is not uniform. For example, the RN shortage is projected to be the most intense in the South and the West (AACN, 2012b). Currently, new graduates are having difficulty finding that first job as a consequence of the declining U.S. economy. Because of economic pressures and job losses in all industries, many nurses increased their hours and/or deferred retirement. Combined with lower hospital census, employers hiring new graduates with bacca- laureate degrees, many open RN positions requiring at least 2 years of experience, and the reputation of new graduates having a high turnover rate, many hospitals have stopped interviewing new gradu- ates (Stokowski, 2011). The health care setting is another factor. The growth of RN positions will occur in community-based settings

adapted in such health care aids as Viewstar (an aid for people with visual impairments), the insulin infusion pump, the voice-controlled wheelchair, magnetic resonance imaging, laser surgery, filtering de- vices for intravenous fluid control devices, and monitoring systems for intensive care.

Information, Telehealth, and Telenursing The Internet has already affected health care, with more and more clients becoming well informed about their health concerns. As a result, nurses may need to interpret Internet sources of information for clients and their families. Because not all of the Internet-based in- formation is accurate, nurses need to become information brokers so they can help people to access high-quality, valid websites; interpret the information; and then help clients evaluate the information and determine if it is useful to them.

The prefix tele means “distance,” and is used to describe the many health care services provided via technology. Telehealth is the “use of medical information exchanged from one site to another via elec- tronic communications to improve the patient’s health status.” The words telemedicine and telehealth are often used interchangeably. Telemedicine is often associated with direct client clinical services, whereas telehealth has a broader definition of remote health care services (IOM, 2012, p. 134). Telenursing is the use of telecommu- nications and information technology to provide nursing practice at a distance (Kumar & Snooks, 2011, p. 1). The delivery of telehealth care, however, is not limited to physicians and nurses; it includes other health disciplines such as radiology, pathology, and pharma- cology. These disciplines also deliver care using electronic infor- mation and telecommunications technologies and are accordingly called teleradiology, telepathology, and telepharmacy. Nurses engaged in telenursing practice continue to use the nursing process to provide care to clients, but they do so using technologies such as the Internet, computers, telephones, videoteleconferencing, and telemonitoring equipment. Telenursing continues to grow, especially in home health care and in rural communities.

Telehealth recognizes no state boundaries and, subsequently, licensure issues have been raised. For example, if a nurse licensed in one state provides health information to a client in another state, does the nurse need to maintain licensure in both states? The National Council of State Boards of Nursing (NCSBN) endorses a change from single-state licensure to a mutual recognition model. Many state leg- islatures have adopted mutual recognition language into statutes and are currently implementing it (see Chapter 4 ).

Legislation Legislation about nursing practice and health matters affects both the public and nursing. Legislation related to nursing is discussed in Chapter 4 . Changes in legislation relating to health also affect nurs- ing. For example, the Patient Self-Determination Act (PSDA) requires that every competent adult be informed in writing on admis- sion to a health care institution about his or her rights to accept or re- fuse medical care and to use advance directives. See Chapter 4 for more information about the PSDA and advance directives.

Health care reform and the shortage of physicians calls for an increase in advance practice registered nurses such as NPs. Cur- rently, there are wide variations in state regulation of nurse prac- titioner practice. For example, 27 states do not require physician