A method used by nurses in dealing with patient problems in professional practice
nursing process
When was the nursing process identified and named?
1960s
What does the nursing process involve?
critical thinking competency that nursing uses to organize and plan patient care
intertwining of thinking and doing
a systemic approach
a problem solving process
purposeful, disciplined, active process that improves clinical judgement and thereby improves patient care
critical thinking
Can critical thinking be a learned process?
yes
What is the purpose of the nursing process?
to provide a framework within which nurses can identify client's health status and assist them in meeting their health needs
Who published the first list of nursing diagnoses in 1973?
NANDA International
has 206 diagnoses approved for clinical testing
What are the characteristics of the nursing process?
dynamic and cyclic
client centered
planned and goal directed
flexible
universally applicable
patient status oriented
cognitive process
What is the value of the nursing process?
promotes collaboration
cost efficient
helps people understand what nurses do
is required by professional standards
promotes client autonomy
promotes individualized care
promotes effciency
promotes continuity and coordination of care
increases job satisfaction
What are some of the key points if the nursing process?
accepted as the "core" of nursing
central to all nursing actions
assures quality of care
Has the nursing process been questioned and if so why?
yes-some people view it as linear, rigid, and mechanistic
despite reservations among some nurses about its use, the nursing process remains the cornerstone of nursing standards, legal definition, and practice and should be understood by EVERY nurse
What are the phases of the nursing process?
assessment
analysis/diagnosis
planning
implementation
evaluation
the systematic process of gathering, verifying, and communicating data about a client
assessment
the process of reviewing a situation for the purpose of identifying the client's needs or problems
assessment
What are the different types of assessment data?
subjective
objective
data that the client tells you, his perceptions
Subjective data
The nursing history is consider what type of data?
subjective data
Subjective data is also refered to as..?
symptoms
"I am in pain" describes what type of data?
subjective data
T/F Subjective data can be very private?
true-nurses must be sensitive to the patients needs for confidence in the nurses' trustworthiness
observations and measurements made by the clinician
objective data
Objective data is also refered to as...?
signs
The physical assessment, vital signs, and lab values are all examples of what type of data?
objective data
T/F Objective and subjective are usually congruent?
true
if data is incongruent, requires further carefull assessment
Primary source of data
the client
Secondary Source of data
family
significant others
health professionals
records
physical examination
How should data be gathered? (before, whhile you see the patient, after)
before: charts, etc.
while: interview, physical exam
after: chart, literature review, etc.
What does the interview involve? What influences the quality of an interview?
face to face interaction with the patient
requires the nurse to use the skills of interviewing, observation, and listening
quality of the interview: privacy, comfort, prescence of other family members
What does the physical exam require?
inspection, palpation, percussion, auscultation
discussing a patients needs with other health care workers and others who are directly involved in the care of the patient (patients family)
consultation
How do we organize the data collected during the assessment phase of the nursing process?
abdellah's 21 nursing problems
henderson's 14 nursing problems
yura and walsh's human needs approach
gordon's 11 functional health patterns
nursing theorists
personal preference
agency method
during this step, the nurse analyzes and synthesizes the assessment data
analysis/diagnosis
Analysis/diagnosis phase is used to do what?
draw specific conclusion
identify areas of positive functioning
identify areas at risk for developing problems
identify areas that are problems
a clinical judgement about an individual, family or community group's response to actual or potential health problems or life processes
nursing diagnosis
a nurse-prescribed intervention that a nurse may legally order or initiate independently...Carpenito
nursing diagnosis
What does the nursing diagnosis identify?
the problems the patient is experiencing as a result of the disease process-the HUMAN RESPONSES to the illness, injury, or threat
Does the nursing diagnosis differ from a medical diagnosis and if so how?
yes-addresses the patients problems that the nurse can treat within their scope of practice
Which phase is considered to be a pivital point in the nursing process and why?
nursing diagnosis
the problems you identify in this phase are the basis for your plan of care
the strengths you identify are invaluable when determining effective nursing interventions
In the analysis/diagnosis phase of the nursing process, data is analyzed and then what?
compared to standards
clustered
gaps and inconsistencies are identified
next, a nursing diagnosis is determined
What does NANDA stand for and what is it?
north american nursing diagnosis association
a taxonomy of nursing diagnosis
types of nursing diagnosis: actual, risk for
NANDA approved nursing diagnosis consist of what 5 components?
label: concise term that names the diagnosis
definition: term that clearly defines meaning and helps differentiate from similar diagnosis
defining characteristics: clusters of observable cues
risk factors: increase vulnerability to an unhealthy event
related factors: related to the diagnosis
What is PES and who developed the term?
Gordon
P=description of the problem "ineffective breathing pattern"
E=etiology or cause "related to"
S=signs and symptoms "as evidenced by" "as manifested by"
How are nursing diagnosis prioritized?
life threatening (1st priority)
potential to cause harm or injury
related to overall health of the patient
Medical diagnosis
disease or pathology of specific organs or body system
cure disease
based on assessment
Nursing Diagnosis
nursing needs of client's heath or illness
assist to adapt to illness or resolve health care problem
based on assessment
The nurse develops a plan of care that prescribes interventions to attain an expected outcome
planning phase
Is planning an ongoing event?
yes-the initial plan is merely a beginning
Why are goals used during the planning phase of the nursing process?
to guide the patient and nurse in the selection of interventions and to evaluate the patients progress
What are the components of the planning phase?
setting priorities
est. expected outcomes or goals
det. nursing interventions
recording the plan of care
specific behavior or response by the client that the nurse anticipates from nursing care, serves as a guidepost to the selection of nursing interventions
goals/outcomes
measureable change in the client's status in response to nursing care, provides direction for nursing interventions
outcome criteria
Goals shoud...?
set a general direction
include an action verb
be both attainable and realistic for the patient
Effective outcome criteria state...?
under what conditions, to what extent, and in what time frame the patient is to act
What are the different types of goals in the planning phase of the nursing process and who developed this?
psychomotor
cognitive
affective
Bloom's taxonomy-describes the type of learning in terms of domains of educational acitivities
involves physical movement and increase complex activities in the motor skill arena
psychomotor goals
learning can be assessed by measures such as distance, time and speed
i.e. patient will move from the bed to a chair 3x today without assistance"
involves knowledge and intellectual skills
cognitive goals
i.e. "patient will list 5 signs of illness in her newborn by the date of hospital discharge"
inolves emotions, feelings, values, attitudes
affective
i.e. "patient wil describe feeling more accepting of new colostomy within 1 week of providing ostomy self-care"
attainable goal within hours or days, specific and are small steps to achievement of a broader goal
short term goal
"patient will lose 2 lbs"
major changes or rehabilitation
long-term goals
"patient will lose 75 lbs"
T/F Setting realistic goals in terms of both outcomes and time is extremely important?
true
NOC
nursing outcomes classification
What are the guidelines for writing goals or outcomes?
outcomes should: r/t the human response, be clear and concise, be measureable, be realistic, be time-limited
-when possible should be determined by the client and nurse together
actions designed to assist the patient in achieving a stated goal
nursing orders
designed to treat a patients response to an illness or medical treatment
interventions
designed to treat the actual disease or illness
medical order
Nursing interventions are activities performed by the nurse to?
monitor the client's health status
prevent, control or resolve problems
assist with ADLs
promote optimum health and independence
requires no supervision or direction by others, what nurses are licensed to do (i.e. teaching a patient how to examine her breasts for lumps, ADLs, education, health promotion, counseling)
independent interventions
requires instructions, written orders, or supervision of another health professional with prescriptive authority (i.e. administering medications)
dependent interventions
actions in which the nurse must collaborate or consult with another health professional before carrying out the action (i.e. protocols)
interdependent interventions
define under what conditions and circumstances a nurse is allowed to treat the patient, used in situations in which nurses need to take immediate action without consulting with a physician
protocols
NIC
nursing interventions classification
the process whereby the nurse implements interventions identified in the plan of care
implementation
The implementation phase of the nursing process is..?
action-oriented and involves coordination of activities of the health care team
puts the nursing care plan into action
the process of doing, delegating and documenting
the nurse evaluates the client's progress toward attainment of goals/outcomes
evaluation phase
What are the components of the evaluation phase of the nursing process?
identify the factors affecting goal/outcome achievement
decide whether to continue, modify or terminate the plan
consists of informed opinions and decision based on empirical knowledge and experience
clinical judgement
What does clinical judgement involve?
critical thinking and clinical reasoning
knowing the limitations of your expertise
applying the nursing process
staying current with development in practice and research
The school of nursing curriculum is divided into 2 major components?
non-clinical courses
clinical courses
Non-clinical courses include?
english, math, natural sciences, arts and humanities
Clinical nursing courses are divided into what 3 levels?
foundations
integrative
synthesis
What is involved in the foundations level of clinical nursing courses?
first 2 semesters
primary focuse is to provide students with the knowledge and skills necessary to progress to higher level clinical
courses include: pathopharm, assessment skills (ind., family and community), basic clinical skills, asult-medical surgical nursing experiences, nursing research, and trend and issues in nursing
What is involved in the integrative level of clinical nursing courses?
3rd and 4th semesters
students learn to incorporate theoretical nursing concepts into practice, while expanding and refining their knowledge
courses include: clients across the lifespan (infants, children, adults, and elderly), special populations (childbearing and psychiatric)
What is involved in the synthesis level of clinical nursing courses?
final semester
student nurse explores the role of the nurse as a leader and manager, while demonstrating a comprehensive understanding of the knowledge base required for professional nursing practice
community capstone project
the philosophical underpinning for the curriculum and provides a guideline for developing goals that will serve as measures for meeting the stated mission
mission statment
inner urge to pursue an activity or perform a service, a calling-what one intends to do or achieve
a mission
What are some of the values implied in the school's mission statement?
leadership
diversity
education
research
health
community
advocacy
advancement
How is the nursing profession regulated?
at the state level by SBNs
legislative body in each state sets practice law and then assigns authority to implement the law (professional practice acts)
What does the State Nurse Practice Act do?
protects the public by broadly defining the legal scope of nursing practice
most important law concerning YOUR nursing practice
legal obligation to practice within the state's nursing practice act
Who is responsible fore enforcing the NPA in various states?
state board of nursing (SBNs)
publicizes rules and regulations that expand the law
What gives meaning to the NPA in each state?
the statutory law + the rules and regulations propagated by the SBN
Is SBNs authority limited and if so how?
yes
does not have the authority to enlarge the law
What are SBNs functions at the executive,legislative, and judicial levels?
executive: authority to administer the NPA
legislative: authority to adopt rules necessary to implement the act
judicial: authority to deny, suspend, or revoke a license or to otherwise discipline a licensee or to deny an applicant for licensure
What are the functions of the NPA?
defines the scope of practice
establish requirements for licensure and entry into practice
create and empower a board to govern licensure and practice
identify grounds for disciplinary action
What is the purpose of the Nurse Practice Act?
to promote, preserve and protect the public health, safety, and welfare by regulating nursing education and practice ensuring that any individual practicing or offering to practice nursing or using the title "RN" or "APRN" shall be licensed before engaging in such practice
T/F The NPA is federal law?
false
What is the most common reason nurses are disciplined by the SBNs?
practicing while impaired
What are some disciplinary actions inforced by the NPA?
denial of licensure
revocation
suspension
probation
placement of conditions
certification of an applicant who is duly licensed as a RN or APRN in another state, territory, or country for licensure to practice as a registered nurse or advanced practice registered nurse in this state
endorsement
What are the qualification for licensure as a RN?
good moral character
completed requirements of nursing education program
passes an examination
completed certain course work
not in violation of rule and regulations
committed no acts or omissions which are grounds for disciplinary action
is proficient in the English language
The Board is composed of how many nurses? Who submits their names? Who appoints them?
9 nurses (8 RNs, 1CRNA)
LA State Nurses Association (headed by executive director-RN)
LA Association of Nurse Anethetists
appointed by the governor
implements the NPA
The Board is composed of how many physicians? Who submits their names? Who appoints them? What is their purpose?
2 physicians
LA State Medical Society
appointed by the governor
serve as advisors and can not vote
Is it a law that a license applicant should be proficient in the English language if he/she graduated from a nursing education program offered in a foreign country?
yes
Who is the current President of the LA State Board of Nursing?
Lucie J. Agosta, PhD, RNC
How are board members compensated for their services?
$75/day
reimbursement for actual expenses and mileage
a group of tasks assigned to one individual
position
a group of positions that are similar in nature and level of skill that can be carried out by one or more individuals
job
a group of jobs that are similar in type of work and that are usually found throughout an industry or work environment
occupation
What are the 2 major differences between an occupation and a profession?
professional preparation
professional committment
an occupation that requires extensive education or a calling that requires special knowledge, skill and preparation
profession
What are the approaches to defining a profession?
process approach
power approach
trait approach
view all occupations as points of development along a continuum, ranging from position to profession (continuum)
process approach
approach to defining a profession that involves independence and power
power approach
identifies traits that define a profession
trait approach
What are some of the changing perceptions of nursing as a profession?
historically a woman's profession
increasing age of the RN
education requirement for entry into the profession
shift from acute care to community and primary care focus
1996-American Association Colleges of Nursing issued a position statement
How and when did Flexner establish the criteria of a profession?
1910
involves a high degree of individual responisibility
possesses a body of specialized knowledge and skills
aims to provide a practical and define service
is characterized by self-organization
motivations tend to be altruistic
What are some common elements of a profession?
specialized training programs (3 levels of education)
unique service to socitey
standards of practice and education
a code of ethical conduct
appropriate public safeguards (licensing exam, SBNs)
self-government
T/F A nurse must hold a valid license to practice?
true
requires any person who practices the profession or occupation to be licensed
mandatory law
protects the use of the title granted in the law but does not prohibit persons from practicing the profession if they do not use the title
permissive law
T/F CNAs may not refer to themselves as nurses?
true
How is one elgible for the licensure examination?
eligible once successfully completed state-approved school of nursing education
What is the licensure exam called and what does it test?
NCLEX (national council licensuring examination)
tests critical thinking and nursing competency in all phases of the nursing process
Is the NCLEX a national exam?
yes
so states recognize the licensure awarded in other states
developed to improve the mobility of nurses, while still protecting the public health, safety, and welfare. allows an RN yo have a license (in state of residency) yet practice in other states without an additional license in the state of employment
nurse licensure compact
occurs in traveling nurses, crossing state lines, telehealth practices, and moving to another state
T/F Other professions have one pathway of educational preparation unlike nursing.
true
What are the 3 pathways to lead to licensure and profession status in nursing?
diploms programs
associate degree programs
baccalaureate programs
Diploma Programs
hospital based
apprenticeship programs
usually 24 months to 3 years in duration
were the first nursing programs to emerge
Florence Nightingale
created first nursing diploma program
St. Thomas Hospital in London (1860)
What programs were considered to be the "famous trio" of diploma programs in the U.S.?
Bellevue Hospital in NY
New England Hospital for Women and Children in New Haven, Conn.
Massachusettes General Hospital in Boston, MA
Why has there been a decline in diploma programs?
growth of AND BSN programs
inability of hospitals to finance nursing education
accreditation standards
increasing complexity of health care
students earn no college credit, but many have gateway course into an ADN program
one diploma program remaining in LA (Baton Rouge General)
Associate Degree Nursing
(when was it est.? who founded it? length? what is the professional organization called? how many programs in LA?)
developed in 1952 to help alleviate the nursing shortage, esp. experienced with WWII
Mildred Montag-founder of Associate Degree Nursing Education
primarily housed in community colleges
usually 2 years in length (minimum of 60 college credits)
NOADN- ADN professional organization
8 ADN programs in LA
What was the progression in developing Baccalaureate Nursing Programs?
1909-University of Minnesota (followed the 3 yr. diploma model)
1919-7 additional BSN programs (most were 5 yrs: 2 yr in liberal arts, 3 yr in nursing)
1924-Yale School of Nursing-first nursing school est. as a seperate university department with an independenet budget and its own dean
current basic program-4 yrs. (minimum 120 college credits), combines general education and nursing courses
What influenced the growth of baccalaureate education?
The Brown Report
ANA Position Paper
The Lysaught Report
The NLN Position Statement
The PEW Commission Report
The Brown Report
Nursing for the Future-1948: report prepared for the National Nursing Council
recommended that basic school of nursing be in universities and colleges and that efforts be made to recruit men and minorities into the programs
ANA Position Paper
1965-Educational Preparation for Nurse Practitioners and Assistants to Nursing: concluded that the BSN should be the foundation for nursing practice
What were the 4 recommendations of the ANA Position Paper?
1. education for all those licensed to practice should take place in institutions of higher learning
2. min. preparation for beginning professional nursing practice should be the BSN
3. min. preparation for beginning technical nursing practice should be the ADN
4. education for assistants in health service occupations should consist of short, intesive programs in vocational education programs rather than on the job training
What were some additional position statements of the ANA in 1979?
proposed that by 1985 entry into practice should be the BSN level
2 levels of nursing practice should be identifies: professional and technical
there should be an increased accessibility to high quality career mobility programs that use flexible approaches to individuals seeking academic degrees
The Lysaught Report
a.k.a.-An Abstract for Action1981-conducted by the National Committee for the Stduy of Nursing and Nursing Education
sponsored by the Kellogg Foundation
recommended 2 licensures for nurses: one in acute care and one in distributive care
NLN Position Statement
1982-The Position Statement on Nursing Rolesreaffirmed the BSN as the minimum educational level for entry into practice for professional nursing, and the ADN as entry into practice for technical nursing
The PEW Commission Report
1995-5 major recommendations:
change professional training to meet the demands of the new-health care system
ensure that the health profession's workforce reflects the diversity of the nation's population
require interdisciplinary competence in health professionals
continue to move education into ambulatory practice
encourage public service of health professionals, students, and graduates
Articulated Nursing Programs
LPN to RN
ADN to RN
Diploma to ADN or RN
ADN to MSN
Alternative Nursing Programs
on-line programs (University of Phoenix, Regents)
Licensed Practical Nurse (Vocational) Programs
licensed as an LVN or LPN
work under the supervision of an RN providing basic, direct patient care
lasts 12 months
must pass the NCLEX-PN to become licensed
considered technical workers
a review process of an educational program by an external professional accrediting organization
accreditation
SBN, NLN-National League for Nursing, CCNE-Commission of Collegiate Nursing Education
Basic education prepares a nurse _____
generalist
Speciality Education
(requirements? available through?)
learned speciality occurs in a hospital program after basic education
as nurses become more active, area of practice become more specialized
certification programs-offer certification in different nursing specialities
general requirements: specific # of practice hours in speciality, certification exam, periodic recertification
available through ANA, NCC
planned learning experiences beyond a basic nursing program
continuing education
Continuing Education (in LA? other states?)
in LA, mandatory continuing education is required to maintain licensure (5CE's-practicing fulltime; 10CE's-practicing part-time; 20CE's-not practicing)
varies by state (no CE requirements in MS, higher yearly CE requirements in TX)
What is considered to be advanced nursing education?
master's degree
doctoral degree
study in one particular subject area to assume advanced roles in practice, education, administration and research
masters degree
History of Master's Level Degree
1899-Teacher's College, NYC (focused on administration and education)
1940s/1950s-saw an increase (return of nurses from military service with GI benefits)
1946-National Mental Health Act (provided funds for psych/mental health nurses)
1954-Rutger's University (1st clinical master's-psych/mental health), clinical nurse specialist
1965-University of Colorado (1st NP program-pediatric)
1970- 70 programs
1996- 321 programs
currents statistics (National Sample Survey of RN, 2000)= MSN (7.5%); related field (2%)
What are the areas included in receiving a masters in nursing?
nursing administration
community health
psychiatric/mental health
adult health
maternal/child nursing
gerontology
rehabilitation
nursing education
What are the requirements for receiving a masters in nursing? Degrees awarded?
entrance requirements: baccalaureate degree, licensure as an RN, completion of GRE, min. GPA of 3.0, recent work related to desired area of concentration
most require 1 year of practice experience
takes 18-24 months to complete, many have 2 focuses
degrees awarded: MA, MN, MSN, MS
can obtain more advanced areas of practice: CRNA, NP, CNS
What is the history of doctural education?
1910-Columbia Teacher's College (EdD, major-nursing education)
1934-NY University (1st PhD program for nurses)
1996- 66 programs
motivation for this degree stems from academic advancement or tenure in educational settings, also includes those nurses interested in research and the development of a body of nursing knowledge
doctural studies
What degrees can be obtained with doctual studies?
DNSc-doctor of nursing science
DSN-doctor of science in nursing (only one available in LA)
DNEd-doctor of nursing education
PhD-doctor of philosophy (not available in nursing in LA)
EdD-doctor of education
current statistics (0.3%-docorate in nursing, 0.3% doctorate in related field)
Florence Nightingale
collected detailed data on morbidity and mortality of soliders during the Crimean War
used data to encourage reform in British army medical system
founded 1st training school for nurses (St. Thomas Hospital in London)
Who established the first nursing training school? When? What was the name of the school?
Florence Nightingale
St. Thomas Hospital in London
1860
American Civil War
1861-1873
at beginning of war, no professional nurse available or organized system of medical care
appointed superintendent of women nurses of the army during the american civil war, created a 2 month long program at 2 NY hospitals for women who wished to serve
Dorothea L. Dix
Harriet Tubman
established underground rr and led numerous slaves to freedom during the American Civil War
Susie King Taylor
black women who taught soldiers how to read and write during the American Civil War
Clara Barton
establsihed her own system of distribution of supplies to soldiers during the american civil war
founded the American Red Cross
"angel of the battlefield"
Sallie Thompkins
assigned by President Jefferson Davis
only women in the confederacy to hold a military rank
What resulted following the American Civil War?
movement toward formal education and licensure
Who were the first training schools for nurses modeled after?
Florence Nightingal's school at St. Thomas in London
"Famous Trio of Nursing Schools"
the first nursing schools established in the US
Bellevue Training School for Nurses in NYC
Conneticut Training School for Nurses in New Haven
Boston Training School for Nurses at Massachusettes General Hosptial
Who was the first trained nurse in the US and when did she graduate?
Linda Richards
1874
Who was the first african american educated nurse in the US?
Mary Eliza Mahoney
What was the first program established exclusively for african american students? Males?
AA-Atlanta Baptist Femal Seminary
Males-School for Male Nursing at NYC Training School
Who founded ANA? When? What was its mission?
Isabel Hampton in 1911
mission to enhance the collaboration among practicing nurses and educators
Internal Council of Nurses (ICN)
dedicated to uniting nursing organizations of all nations
first meeting held at Worl Exposition in Buffalo, NY in 1901
changed practice of nursing dramatically: state registration of nurses
National Association of Colored Graduate Nurses
founded by Martha Franklin to break down discrimination but the group dissolved in 1951 when goals had been met and ANA accepted blacks into their organization
Henry Street Settlement
founded by Lillian Wald
first formalized public health nursing practice
Margaret Sanger
safe contraception and family planning
Jessie Sleet Scales
african american nurse hired to work in the african american community to persuade people to accept TB treatment
Stillman House
a branch of the Henry St. Settlement
served colored people
established by ELizabeth Tyler and Scales
Anita McGee
appointed head of the Hospital Corps during the spanish-american war
lead to the development of the Army Nurse Corps and Navy Nurse Corps
When was licensure fully mandated?
1947
When was the first nationwide state board exam and who administered the exam?
1950
NLN
What happened during WWI?
national campaign launched to recruit women to enter nursing training
flu epidemic increased the public's awareness of the necessity of public health nursing
1920 congress passed a bill that provided nurses with military rank
increase in the use of hospitals
Goldmark Report
study of nursing education that advocated the establishment of collegiate schools of nursing rather than hospital-basde diploma programs
Frontier Nursing Services
established by Mary Breckinridge
first organized midwifery program in the US
traveled to serve the health needs of poverty-stricken mountain people
What challenges did nurses face during the great depression and WW2?
hospitals were largely staffed by nursing students
most graudate nurses worked as provate duty nurses in patients homes
great depression caused many families not to be able to afford nursing services, forcing many nurse into unemployment
President Franklin D. Roosevelt established the Civil Works administration for nurses to participate by providing rural and school health services
many schools of nursing forced to close due to economic turmoil
social security act enhanced the practice of public health nursing
What opportunities did nurses receive during WW2?
inadequate supply of nurses
congress enacted legislation to provide money for nursing education
Cadet Nurse Corps
program created during WW2 where students received tuition, book, a stipent, etc. in return for a promise to serve as nurses for the duration of the war
Hill-Burton Act
funds to construct hospitals and lead to a surge in the growth of new facilities
lead to a shortage of nurse and difficult working condition
team nursing developed
When was Medicare and Medicaid established?
during Vietnam
What developed in the field of nursing during the Vietnam War?
clinical specialization: NP
mobile hospital units in jungles
many nurses suffered PTSD after returning home from the war
Agenda for health care reform in 1992
focused on reconstructing the health care system and to reduce costs and improve access to care
What are some of the challenges facing the field of nursing today?
diagnostic-related groups
third part reimbursement for advanced practice nurses
electronic medical records
issues similar to the past: war, epidemics, poverty, immigration
language barriers with Latino immigrants in the US
