essay on importance of nursing

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Why nurses are the heart of healthcare.

If you’ve never been cared for by a nurse, you likely will be eventually.

Nurses are the foundation of healthcare. They play a vital role in providing care, comfort and compassion for their patients and patients’ families.

Despite their caring demeanor, nurses would rather not see you in the hospital. Preventive healthcare is their priority for patients — getting regular checkups and keeping health concerns from developing into a serious condition is key to avoiding the hospital, not to mention the intensive care unit.

"One of the biggest things is preventative healthcare," says Marguerite Manseau, RN , at Edward Hospital. “If your baseline overall health that has accumulated over 40 plus years is not good, a lot of the conditions people develop that land them in the hospital are not as easy to cure."

Many chronic conditions can be prevented by living a healthier lifestyle.

Also, stay on top of warning signs. "Listen to your body. If something doesn't feel right, get it checked out," says Marijana Vidovic, RN , at Elmhurst Hospital.

What it means to be a nurse

Being a nurse isn’t always easy. Nurses work hard. During the pandemic, and even before, nurses have experienced burnout. They emotionally invest in their patients and patients’ families, which can be exhausting during tough times. It’s even contributed to a national nurse shortage.

There are also times nurses need a thick skin. They can face heartbreaking situations, and it can be a stressful job. But nurses are realistic. Knowing what to expect and having the support of a team helps them get through stressful times.

"Having a level head is sometimes difficult. We're human and have emotions," Manseau says. "There are days you leave work and you're just so physically tired from not just how much physical work you've done but how much mental work. That accumulates over time.

"Being bombarded by anything and everything for 12 hours means nurses need to find healthy channels to get support and blow off steam so we avoid compassion fatigue."

Staying in the moment and maintaining perspective helps, the nurses say. Connection with the nursing team is also crucial for mental well-being, as nursing coworkers understand what each other is facing and can offer vital support.

The rewards

Becoming a nurse starts with nursing school. A good foundation in nursing school helps nurses understand and think critically about their duties.

Technology is involved in every aspect of a nurse’s day. From electronic records to the pharmacy and bedside technology, nurses need to know how it all works.

Nurses don’t just provide clinical care and medication, they provide emotional support for their patients and the patient’s family members, which is particularly important in the hospital where it helps to have a human connection during what is often a scary time.

Nurses work together and help coordinate care from physicians, physical therapists and others to do what's best for each patient. Working with the team is a rewarding part of the job, says Vidovic. Watching a patient walk out of the hospital after a lengthy hospitalization or being on a ventilator is also an amazing reward, they say.

Nurses are needed now more than ever

Nurses are in high demand, as the American healthcare industry faces a shortage of nurses. And it’s not just bedside nurses — there is so much you can do as a nurse beyond working in a hospital. You can become a teacher; you can become an APN. You can always expand your skills — specialize, do clinicals or teach. That's the beauty of a nursing degree.

"Really, if you think about your daily life, there's probably a nurse involved in some capacity at every step,” Manseau says. “Elementary school, there’s a nurse. You can work in an operating room. You can work at the bedside. You can teach. If you have a specific interest in something, you can find a program to get certified in it.”

Nurses are an unstoppable force. Providing care, comfort and compassion is all in a day’s work. In this Health 360 with Dr. G podcast episode, “Shout out to nurses: Heroes in healthcare,” host Mark Gomez, MD, and his guests discuss nurse life and the future of nursing. Listen to the podcast.

Edward-Elmhurst Health is hiring nurses! Learn more about nursing and search for nursing opportunities.

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How to Write a Nursing Essay with a Quick Guide

Ever felt the blank-page panic when assigned a nursing essay? Wondering where to start or if your words will measure up to the weight of your experiences? Fear not, because today, we're here to guide you through this process.

Imagine you're at your favorite coffee spot, armed with a cup of motivation (and maybe a sneaky treat). Got it? Great! Now, let's spill the secrets on how to spin your nursing tales into words that not only get you that A+ but also tug at the heartstrings of anyone reading. We've got your back with nursing essay examples that'll be your inspiration, an outline to keep you on the right path, and more!

What Is a Nursing Essay

Let's start by dissecting the concept. A nursing essay serves as a focused exploration of a specific aspect of nursing, providing an opportunity for students to demonstrate their theoretical knowledge and its practical application in patient care settings.

Picture it as a journey through the challenges and victories of a budding nurse. These essays go beyond the classroom, tackling everything from tricky ethical dilemmas to the impact of healthcare policies on the front lines. It's not just about grades; it's about proving, 'I'm ready for the real deal.'

So, when you read or write a nursing essay, it's not just words on paper. It's like looking into the world of someone who's about to start their nursing career – someone who's really thought about the ins and outs of being a nurse. And before you kick off your nursing career, don't shy away from asking - write my essay for me - we're ready to land a professional helping hand.

How to Start a Nursing Essay

When you start writing a nursing essay, it is like gearing up for a crucial mission. Here's your quick guide from our nursing essay writing service :

Choosing Your Topic: Select a topic that sparks your interest and relates to real-world nursing challenges. Consider areas like patient care, ethical dilemmas, or the impact of technology on healthcare.

Outline Your Route : Plan your essay's journey. Create a roadmap with key points you want to cover. This keeps you on track and your essay on point.

Craft a Strong Thesis: Assuming you already know how to write a hook , kick off your writing with a surprising fact, a thought-provoking quote, or a brief anecdote. Then, state your main argument or perspective in one sentence. This thesis will serve as the compass for your essay, guiding both you and your reader through the rest of your writing.

How to Structure a Nursing Essay

Every great essay is like a well-orchestrated performance – it needs a script, a narrative that flows seamlessly, capturing the audience's attention from start to finish. In our case, this script takes the form of a well-organized structure. Let's delve into the elements that teach you how to write a nursing essay, from a mere collection of words to a compelling journey of insights.

Nursing Essay Introduction

Begin your nursing essay with a spark. Knowing how to write essay introduction effectively means sharing a real-life scenario or a striking fact related to your topic. For instance, if exploring patient care, narrate a personal experience that made a lasting impression. Then, crisply state your thesis – a clear roadmap indicating the direction your essay will take. Think of it as a teaser that leaves the reader eager to explore the insights you're about to unfold.

In the main body, dive into the heart of your essay. Each paragraph should explore a specific aspect of your topic. Back your thoughts with examples – maybe a scenario from your clinical experience, a relevant case study, or findings from credible sources. Imagine it as a puzzle coming together; each paragraph adds a piece, forming a complete picture. Keep it focused and let each idea flow naturally into the next.

Nursing Essay Conclusion

As writing a nursing essay nears the end, resist the urge to introduce new elements. Summarize your main points concisely. Remind the reader of the real-world significance of your thesis – why it matters in the broader context of nursing. Conclude with a thought-provoking statement or a call to reflection, leaving your reader with a lasting impression. It's like the final scene of a movie that leaves you thinking long after the credits roll.

Nursing Essay Outline

Before diving into the essay, craft a roadmap – your outline. This isn't a rigid skeleton but a flexible guide that ensures your ideas flow logically. Consider the following template from our research paper writing service :

Introduction

Opening Hook: Share a brief, impactful patient care scenario.
Relevance Statement: Explain why the chosen topic is crucial in nursing.
Thesis: Clearly state the main argument or perspective.

Patient-Centered Care:

Definition: Clarify what patient-centered care means in nursing.
Personal Experience: Share a relevant encounter from clinical practice.
Evidence: Integrate findings from reputable nursing literature.

Ethical Dilemmas in Nursing Practice

Scenario Presentation: Describe a specific ethical challenge faced by nurses.
Decision-Making Process: Outline steps taken to address the dilemma.
Ethical Frameworks: Discuss any ethical theories guiding the decision.

Impact of Technology on Nursing

Current Trends: Highlight technological advancements in nursing.
Case Study: Share an example of technology enhancing patient care.
Challenges and Benefits: Discuss the pros and cons of technology in nursing.
Summary of Key Points: Recap the main ideas from each section.
Real-world Implications: Emphasize the practical significance in nursing practice.
Closing Thought: End with a reflective statement or call to action.

A+ in Nursing Essays Await You!

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Nursing Essay Examples

Here are the nursing Essay Examples for you to read.

Writing a Nursing Essay: Essential Tips

When it comes to crafting a stellar nursing essay, a few key strategies can elevate your work from ordinary to exceptional. Here are some valuable tips from our medical school personal statement writer :

Connect with Personal Experiences:

Approach: Weave personal encounters seamlessly into your narrative.
Reasoning: This not only adds authenticity to your essay but also serves as a powerful testament to your firsthand understanding of the challenges and triumphs in the nursing field.

Emphasize Critical Thinking:

Approach: Go beyond describing situations; delve into their analysis.
Reasoning: Nursing essays are the perfect platform to showcase your critical thinking skills – an essential attribute in making informed decisions in real-world healthcare scenarios.

Incorporate Patient Perspectives:

Approach: Integrate patient stories or feedback into your discussion.
Reasoning: By bringing in the human element, you demonstrate empathy and an understanding of the patient's experience, a core aspect of nursing care.

Integrate Evidence-Based Practice:

Approach: Support your arguments with the latest evidence-based literature.
Reasoning: Highlighting your commitment to staying informed and applying current research underscores your dedication to evidence-based practice – a cornerstone in modern nursing.

Address Ethical Considerations:

Approach: Explicitly discuss the ethical dimensions of your topic.
Reasoning: Nursing essays provide a platform to delve into the ethical complexities inherent in healthcare, showcasing your ability to navigate and analyze these challenges.

Balance Theory and Practice:

Approach: Connect theoretical concepts to real-world applications.
Reasoning: By bridging the gap between theory and practice, you illustrate your capacity to apply academic knowledge effectively in the dynamic realm of nursing.

Highlight Interdisciplinary Collaboration:

Approach: Discuss collaborative efforts with other healthcare professionals.
Reasoning: Acknowledging the interdisciplinary nature of healthcare underscores your understanding of the importance of teamwork – a vital aspect of successful nursing practice.

Reflect on Lessons Learned:

Approach: Conclude with a thoughtful reflection on personal growth or lessons from your exploration.
Reasoning: This not only provides a satisfying conclusion but also demonstrates your self-awareness and commitment to continuous improvement as a nursing professional.

As we wrap up, think of your essay as a story about your journey into nursing. It's not just about getting a grade; it's a way to share what you've been through and why you want to be a nurse.

Imagine the person reading it – maybe a teacher, a future coworker, or someone starting their nursing journey. They're trying to understand your passion and why you care about nursing.

So, when you write, remember it's more than just an assignment. It's your chance to show why nursing matters to you. And if you ever need help – there's always support from our essay writer online .

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How to Write a Nursing Essay?

How can a nursing essay effectively address ethical considerations, what are some examples of evidence-based practices in nursing essays, related articles.

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Tips for Writing Your Nursing Program College Essays

This article was written based on the information and opinions presented by Giebien Na in a CollegeVine livestream. You can watch the full livestream for more info.

What’s Covered:

The importance of your college essays, general advice for writing your nursing essays.

If you know you want to be a nurse, you probably have quite a few reasons for that. Instead of merely relying on your academic and test performances to tell your story, you get the opportunity in your essays to share exactly why you’re so passionate about nursing. Writing about this can be a clarifying and even exciting process. This article explains why college application essays matter and how you should write about why you want to become a nurse.

Grades and test scores matter when you’re applying to college, but your essays can help improve your chances of admission. They’re how you can express your experiences and make your desire to become a nurse clear and personal.

If your prospective school doesn’t have supplemental essays, it’s a good idea to include your interest in nursing in your Common App essay . This could mean that you end up with two different drafts of the essay: one for if there are supplemental essays where you can discuss your interests in nursing and one for if there are not. You’ll change them out depending on whether you also have to respond to specific prompts about why you want to pursue nursing. This may not sound like much fun, but it will help you be admitted to your school of choice.

It might seem exciting to apply to a place where you don’t have to write extra essays—it’s less work! If you don’t do that additional work, though, you’ll have fewer chances to explain yourself. You might not be able to share exactly why you think that you’re the right fit for a certain college or program.

If you are writing supplemental essays for the colleges that you’re interested in, you can include more details about your passion for nursing. You’ll often be asked, “why this major?” or “why this school?” When you have those opportunities to share your specific reasons, you can let yourself get personal and go deep into your passion. Use that space to share important details about who you are.

Start Broad

When writing essays entirely about why you want to pursue nursing , try to start from a broad interest, then slowly work your way to telling specific personal stories and goals.

When first thinking about your general interest in nursing, ask yourself what attracts you to the work of being a nurse. This can lead to powerful potential responses. Maybe you like taking care of people in the community. Perhaps you’ve always known that you wanted to make a difference in the healthcare profession, but you don’t want to be a doctor. You’d rather make patients’ healthcare experiences as comfortable and pleasant as possible.

After you’ve described these broad, overarching motivations for wanting to go into nursing, consider any personal experiences that have made you want to be a nurse. Think about moments you’ve had during hospital visits or checkups or an anecdote from a time that you decided to volunteer in a healthcare role. Once you’ve written these stories, you can end the essay by discussing your planned major and career goals.

Discuss Your Future Goals

If you know what your end goal is, be sure to include it. You can write about becoming a registered nurse or maybe a nurse practitioner. It doesn’t have to be set in stone , but sharing a final ambition can help anchor your personal narrative. Writing about the future that you want can help the admissions officer reading your essay see how you view yourself. If they can do this, they’ll better understand your values and motivations and see you as a real candidate for their school.

You don’t have to follow this pattern exactly. For example, it can be powerful to begin your essay in the middle of the action—you can dive right into an anecdote and get the reader interested in your story from the jump.

While you should avoid dramatization, starting with a few clear, memorable scenes or a line or two of dialogue can make for an instantly interesting essay. All of this helps you show your passion, rather than simply explaining what intrigues you about a nursing career.

Once you’ve led with your narrative, though, remember to ground it in clear reasons for your intended career and what you want your future to look like. A good essay will be balanced between the past, present, and future. It’s how a college will see who you are and everything that you have to offer.

1.4: Relevance of Scholarly Writing to the Nursing Profession

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Lapum et al.
Ryerson University (Daphne Cockwell School of Nursing) via Ryerson University Library

Scholarly writing is a form of communication and a necessary skill that is important to the nurse’s role as a clinician, professional, a leader, a scholar, an educator, and an advocate. As a student, developing skills in scholarly writing will help prepare you for your nursing role.

Types of scholarly writing that you may be involved in as a nurse are:

Social awareness and advocacy campaigns in which you share knowledge and bring awareness to an issue or a new policy.
Educating and influencing people and communities. The power of writing provides a means for nurses to state their position and influence others. Nurses are involved in crafting policy ideas to influence stakeholders and government bodies on public health issues.
Best practice guidelines, standards of practice, and policies and procedures to inform nursing practice.
Research grants and manuscripts for publication.
Reflective practice, which is a professional expectation for nurses to demonstrate their commitment to life-long learning and continuing competence by reflecting on their practice (College of Nurses of Ontario, 2018).

Nurses may engage in scholarly writing in ways that differ from other disciplines . For example:

As noted above, nurses engage in many forms of scholarly writing, so you should be prepared to tailor the style of writing to your audience and your objectives.
In nursing and other health-related fields, you must incorporate evidence to support your statements.
It is important that you draw from scholarly sources, such as peer-reviewed journals, as opposed to magazines or books.
You need to be clear and concise, with a logical flow in your writing from point A to B.
Scholarly writing allows you develop your capacity as a communicator, a skill that transcends domains of professional and personal life.

College of Nurses of Ontario (2018, October). QA Program. Retrieved from https://www.cno.org/en/myqa/

Nursing Essay Topics

Nursing School Essay Topics

The importance of effective communication in nursing practice
Addressing health disparities in underserved communities: a nursing perspective
Nursing leadership and management: strategies for successful team building
Ethical dilemmas in nursing: balancing patient autonomy and professional obligations
Enhancing patient safety through evidence-based nursing practice
The role of nursing in chronic disease management and prevention
Nursing education and career development: challenges and opportunities
Nursing informatics: leveraging technology to improve patient outcomes
Promoting cultural competence in nursing practice: strategies for success
The impact of COVID-19 on nursing practice and the healthcare system

Nursing Admission Essay Topics

How my life experiences have prepared me for a career in nursing
Overcoming challenges to pursue a career in nursing
My passion for nursing and how it began
The importance of empathy and communication skills in nursing
Diversity and cultural competence in nursing
How nursing aligns with my personal and professional goals
The role of technology in modern nursing practice
Nursing ethics and the importance of patient-centered care
Reflection on a meaningful patient interaction and its impact on my nursing career
The challenges and rewards of being a nurse leader.

Professional Nursing Essay Ideas

The evolution of nursing: From Florence Nightingale to modern practice
Addressing burnout and compassion fatigue in nursing: Strategies for self-care
The importance of advocacy in nursing: Ensuring patient rights and social justice
The role of interdisciplinary collaboration in achieving positive patient outcomes
The future of nursing education: Adapting to changing healthcare needs
Nursing and healthcare policy: Understanding the political landscape
Nursing research: Utilizing evidence-based practice to improve patient care
Promoting health equity in nursing practice: Recognizing and addressing health disparities
The intersection of technology and nursing: Opportunities and challenges
Global health and nursing: Addressing healthcare disparities in low- and middle-income countries.

Persuasive Nursing Essay Topics

Should hospitals and healthcare organizations be required to implement nurse-to-patient staffing ratios to improve patient outcomes?
Should nurses be allowed to prescribe certain medications and treatments to improve patient access to care?
Should more resources be dedicated to nursing research to inform evidence-based practice and improve patient outcomes?
Should nursing education place greater emphasis on pain management to better serve patients with chronic pain?
Should healthcare organizations invest in more technology to improve patient monitoring and reduce errors?
Should nurses be given more autonomy in decision-making to improve patient outcomes?
Should healthcare organizations prioritize patient-centered care over cost-cutting measures?
Should healthcare organizations offer more support and resources for nurses to prevent burnout and improve job satisfaction?
Should more attention be given to patient education to improve patient self-management and outcomes?
Should organizations invest in more cultural competency training for nurses to better serve diverse patient populations?

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Nursing Argumentative Essay Topics

Should nurses be allowed to prescribe medication independently?
Is it ethical for healthcare facilities to mandate flu vaccination for nurses and other healthcare workers?
Should nursing students be required to pass a standardized competency exam before being licensed as a registered nurse?
Is mandatory overtime for nurses an effective strategy for addressing staffing shortages?
Should advanced practice registered nurses (APRNs) be granted full practice authority?
Should nurses be required to report colleagues who exhibit unsafe or unprofessional behavior?
Should nursing homes be required to maintain minimum staffing ratios for nurses and certified nursing assistants?
Should nurses be allowed to assist terminally ill patients with voluntary euthanasia or physician-assisted suicide?
Should healthcare facilities be held responsible for workplace violence against nurses and other healthcare workers?
Should nurses be allowed to unionize and engage in collective bargaining?

Reflective Essay Topics Nursing

Lessons learned from a challenging patient interaction
A personal experience that highlighted the importance of communication in nursing
How a nursing mentor or preceptor helped shape your professional development
The impact of cultural competency on your nursing practice
A case where you advocated for a patient's rights and how it influenced your nursing practice
A situation where you made a mistake and the lessons learned from it
A difficult ethical dilemma you faced in your nursing practice and how you navigated it
A memorable patient case that challenged your clinical skills and knowledge
How nursing education has influenced your nursing practice and professional development
Reflections on the importance of self-care for nurses and how you prioritize it in your own practice.

Compare and Contrast Nursing Essay Topics

Compare and contrast the healthcare outcomes of patients suffering from chronic illnesses who have access to regular nursing care versus those who do not.
Compare and contrast the incidence of racial discrimination in nursing care between urban and rural areas.
Compare and contrast the health risks associated with nursing care in acute care settings versus primary care settings.
Compare and contrast the effectiveness of medication-based treatments versus non-pharmacological interventions for managing pain in patients suffering from chronic illnesses.
Compare and contrast the communication styles and techniques used by nurses in caring for patients from different cultural backgrounds.
Compare and contrast the approaches to patient education used by nurses in acute care settings versus those in community health settings.
Compare and contrast the nursing interventions used for preventing and treating pressure ulcers in patients who are bedridden versus those who are mobile.
Compare and contrast the use of traditional nursing care models versus patient-centered care models in addressing the needs of patients suffering from mental health disorders.
Compare and contrast the ethical considerations involved in providing nursing care to patients who are terminally ill versus those who are not.
Compare and contrast the nursing interventions used to prevent and treat complications associated with diabetes in pediatric versus adult patients.

Nursing Informatics Essay Topics

The role of nursing informatics in improving patient safety
The benefits and challenges of implementing electronic health records in nursing practice
Using data analytics to identify trends and improve patient outcomes
The impact of nursing informatics on clinical decision-making
The importance of user-centered design in nursing informatics
The ethical implications of using patient data in nursing informatics
The role of telehealth in nursing informatics and improving access to care
The future of nursing informatics and emerging technologies in healthcare
The impact of nursing informatics on interdisciplinary collaboration and communication
Using nursing informatics to promote population health and improve public health outcomes.

Evidence-Based Practice Nursing Essay Topics

The importance of evidence-based practice in nursing and its impact on patient outcomes
A case study of the successful implementation of evidence-based practice in nursing
Strategies for overcoming barriers to evidence-based practice in nursing
The role of nursing research in supporting evidence-based practice
The challenges of translating research into practice in nursing
The importance of collaboration between nurses and other healthcare professionals in promoting evidence-based practice
A comparison of different evidence-based practice models in nursing
The role of technology in promoting evidence-based practice in nursing
The impact of evidence-based practice on healthcare disparities and equity
The future of evidence-based practice in nursing and emerging trends in the field.

Good Nursing Essay Topics

The impact of caring on nursing practice and patient outcomes
Strategies for preventing and managing nursing burnout
The importance of cultural competency in nursing practice and improving patient care
The role of nursing in promoting health equity and addressing healthcare disparities
A personal experience that influenced your decision to become a nurse
The impact of technology on nursing practice and patient care
The importance of interprofessional collaboration in nursing practice
The role of nursing leadership in shaping healthcare policy and practice
Ethical issues in nursing practice and their impact on patient care
The impact of the COVID-19 pandemic on nursing practice and healthcare delivery.

Interesting Nursing Essay Topics Ideas

The benefits and challenges of working in rural nursing
The role of simulation in nursing education and its impact on clinical preparedness
A personal experience that highlighted the importance of compassion in nursing practice
The impact of social determinants of health on nursing practice and patient outcomes
The role of nurses in promoting mental health and wellbeing
A comparison of different nursing specialties and their unique challenges and rewards
The importance of patient-centered care in nursing practice and its impact on patient outcomes
The role of nurses in addressing the opioid epidemic and promoting safe pain management practices
The impact of environmental factors on nursing practice and patient outcomes
The benefits and challenges of international nursing and working in global health.

Nursing Essay Questions

How has your understanding of nursing changed since starting your education and clinical practice?
What is the most significant challenge you have faced as a nursing student or professional, and how did you overcome it?
How has the nursing profession evolved over time, and what do you see as its future direction?
In your opinion, what are the most important qualities for a nurse to possess, and why?
How can nursing education and practice be improved to better meet the needs of diverse patient populations?
How can nurses effectively communicate and collaborate with other healthcare professionals to ensure optimal patient care?
What role does evidence-based practice play in nursing, and how can it be effectively integrated into clinical practice?
What ethical dilemmas do nurses face in their daily practice, and how can they be addressed?
How has the COVID-19 pandemic impacted nursing practice and healthcare delivery, and what lessons can be learned from this experience?
How can nurses play a greater role in promoting public health and preventing disease in their communities?

Mental Health Nursing Essay Topics

The impact of stigma on mental health care and nursing practice
A comparison of different mental health nursing interventions and their effectiveness
The importance of trauma-informed care in mental health nursing practice
The role of nursing in promoting recovery-oriented care in mental health settings
The benefits and challenges of telepsychiatry and its impact on mental health nursing practice
The impact of cultural factors on mental health nursing practice and patient outcomes
The importance of self-care for mental health nurses and strategies for preventing burnout
The role of nursing in addressing the mental health needs of diverse populations, including LGBTQ+ and immigrant communities
A personal experience that highlighted the importance of compassion in mental health nursing practice
The role of mental health nurses in the prevention of suicide amongst adolescents.

Breastfeeding Essay Topics for Nursing Students

The benefits of breastfeeding for mother and baby and the role of nursing in promoting and supporting breastfeeding
A comparison of different breastfeeding positions and techniques and their effectiveness
The impact of cultural factors on breastfeeding practices and nursing interventions
The importance of evidence-based practice in promoting breastfeeding and improving outcomes for mothers and babies
Strategies for addressing common breastfeeding challenges and promoting successful breastfeeding outcomes
The impact of workplace policies on breastfeeding practices and the role of nursing in advocating for supportive policies
The role of nursing in addressing disparities in breastfeeding rates among different populations, including low-income and minority communities
The benefits and challenges of breastfeeding for preterm and medically fragile infants and the role of nursing in providing specialized care
The impact of breastfeeding on maternal mental health and the role of nursing in addressing postpartum depression and anxiety
The impact of the COVID-19 pandemic on breastfeeding practices and nursing interventions.

Public Health Nursing Topics

The role of public health nursing in addressing health disparities and promoting health equity
The impact of social determinants of health on public health nursing practice and patient outcomes
Strategies for addressing common public health challenges, including infectious disease outbreaks and environmental hazards
The importance of community engagement and advocacy in public health nursing practice
The impact of cultural factors on public health nursing practice and patient outcomes
The role of nursing in addressing global health challenges, including maternal and child health, infectious diseases, and non-communicable diseases
The benefits and challenges of interprofessional collaboration in public health nursing practice
The importance of evidence-based practice in public health nursing and its impact on patient outcomes
The impact of technology on public health nursing practice, including data analytics and telehealth
The role of public health nursing in promoting health education and disease prevention, including the importance of health screenings and immunizations.

Infection Control/Prevention Nursing Topics

The importance of hand hygiene in preventing healthcare-associated infections
The role of the infection preventionist in promoting a culture of safety and reducing the risk of infections
Strategies for preventing the spread of antibiotic-resistant organisms in healthcare settings
The impact of environmental cleaning and disinfection on infection control
The use of personal protective equipment (PPE) in preventing the spread of infections in healthcare settings
The role of vaccination in infection prevention, including vaccine hesitancy and strategies to improve vaccination rates
The impact of COVID-19 on infection control and prevention practices in healthcare settings
The impact of nursing leadership and education on infection control practices
The role of surveillance in detecting and preventing infections in healthcare settings
The challenges of infection control and prevention in long-term care facilities and strategies for improving outcomes.

Midwife, Neonatal, and Pediatric Nursing Essay Topics

The importance of antenatal care and screening for maternal and fetal health
The role of the midwife in providing support and care during labor and delivery
Strategies for reducing maternal and neonatal mortality and morbidity rates in low-resource settings
The impact of perinatal mental health on maternal and neonatal outcomes
The role of the neonatal nurse in caring for premature and critically ill infants in the neonatal intensive care unit (NICU)
The impact of developmental care on the health and well-being of premature infants
The importance of family-centered care in neonatal and pediatric nursing practice
The role of the pediatric nurse in caring for children with chronic illnesses and disabilities
The impact of trauma-informed care on the health outcomes of pediatric patients
The importance of nursing leadership and education in improving neonatal and pediatric healthcare outcomes.

Trauma and Acute Care Nursing Topics

The role of the trauma nurse in managing critically injured patients in the emergency department
The impact of trauma-informed care on patient outcomes in the acute care setting
Strategies for reducing preventable adverse events in the acute care setting
The role of the nurse in managing acute pain in critically ill patients
The impact of delirium on patient outcomes in the acute care setting
The importance of early mobilization in the management of critically ill patients
The role of the nurse in caring for patients with acute respiratory distress syndrome (ARDS)
The impact of sepsis on patient outcomes in the acute care setting
Strategies for reducing hospital readmissions in patients with complex medical conditions
The role of the nurse in caring for patients with acute neurological emergencies.

How To Choose a Topic for a Nursing Essay?

When it comes to choosing a topic for a nursing essay, there are several factors you should consider. Here are some steps to help you choose a nursing essay prompt:

Identify your interests: Start by thinking about topics that interest you or that you are passionate about. This can help you stay engaged and motivated throughout the essay-writing process.
Consider your audience : Think about who your audience will be, and choose a topic that will be relevant and interesting to them. For example, if you are writing for a nursing journal, you may want to choose a topic related to current nursing practices or research.
Focus on a specific aspect of nursing: Nursing is a broad field, so it's important to narrow down your focus to a specific area of nursing. For example, you could write about a specific disease or condition, or a specific nursing intervention.
Research the topic: Before finalizing your topic, do some preliminary research to make sure there is enough information available on the topic. Look for scholarly articles, books, and other reliable sources to ensure that your topic is well-supported.
Consult with your instructor: Be sure to consult with your instructor to ensure that your topic meets the assignment requirements.

In summary,

We hope these nursing essay prompts have inspired you to write an outstanding essay that showcases your unique qualities.

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11.

Cover of The Future of Nursing 2020-2030

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

Hardcopy Version at National Academies Press

4 The Role of Nurses in Improving Health Care Access and Quality

Of all the forms of inequality, injustice in health care is the most shocking and inhumane. —Dr. Martin Luther King, civil rights activist

Nurses can be key contributors to making substantial progress toward health care equity in the United States in the decade ahead by taking on expanded roles, working in new settings in innovative ways, and partnering with communities and other sectors. But the potential for nurses to help people and communities live healthier lives can be realized only if the barriers to their working to the full extent of their education and training are removed. To this end, it will be necessary to revise scope-of-practice laws, public health and health system policies, state laws regarding the use of standing orders, and reimbursement rules for Medicare and other payers. Major shifts occurring both within society at large and within health care will transform the environment in which the next generation of nurses will practice and lead. If health care equity is to be fully achieved, nursing schools will need to focus on ensuring that all nurses, regardless of their practice setting, can address the social factors that influence health and provide care that meets people where they are.

Health care equity focuses on ensuring that everyone has access to high-quality health care. As shown in the Social Determinants of Health and Social Needs Model of Castrucci and Auerbach (2019) (see Chapter 2 ), health care is a downstream determinant of health, but disparities in health care access and quality can widen and exacerbate disparities produced by upstream and midstream determinants of health outcomes.

According to Healthy People 2020, access to quality health care encompasses the ability to gain entry into the health care system through health insurance, geographic availability, and access to a health care provider. Health care quality has been defined as “the degree to which health care services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge” ( IOM, 1990 , p. 4). The Agency for Healthcare Research and Quality (AHRQ) defines quality health care “as doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results” ( Sofaer and Hibbard, 2010 ). Nurses deliver high-quality care by providing care that is safe, effective, person-centered, timely, efficient, and equitable ( IOM, 2001 ).

As noted, frameworks for social determinants of health (SDOH) place the health care system downstream, often operating in response to illness, rather than upstream, impacting the underlying causes of health outcomes ( Castrucci and Auerbach, 2019 ). Therefore, health care itself does not address most of the upstream factors, or root causes of illness, that affect health equity; such upstream social factors as economic and housing instability, discrimination and other forms of racism, educational disparities, and inadequate nutrition can affect an individual’s health before the health care system is ever involved ( Castrucci and Auerbach, 2019 ). Health equity is discussed in detail in Chapter 5 . Some estimates indicate that a small portion of health outcomes is related to health care, while equity in health care is an important contributing factor to health equity ( Hood et al., 2016 ; Remington et al., 2015 ).

Major shifts occurring both within society at large and within health care will transform the environment in which the next generation of nurses will practice and lead. These shifts encompass changing demographics, including declining physical and mental health; increased attention to racism and equity issues; the development and adoption of new technologies; and changing patterns of health care delivery. The widespread movement for racial justice, along with the stark racial disparities in the impacts of COVID-19, has reinforced the nursing profession’s ethical mandate to advocate for racial justice and to help combat the inequities embedded in the current health care system. The commitment to social justice is reflected in provision 9 of the Code of Ethics of the American Nurses Association ( ANA, 2015 ), and its priority has been elevated by the increased demand for social justice within communities and society at large.

Changing health outcomes will require action at all levels—upstream, midstream, and downstream—and nurses have a major role at all levels in reducing gaps in clinical outcomes and improving health care equity. Nurses can strengthen their commitment to diversity, equity, and inclusion by leading large-scale efforts to dismantle systemic contributors to inequality and create new norms and competencies within health care. In that process, nurses will need to meet the complex ethical challenges that will arise as health care reorients to respond to the rapidly changing landscape ( ANA, 2020 ; Beard and Julion, 2016 ; Koschmann et al., 2020 ; Villarruel and Broome, 2020 ). To ensure nursing’s robust engagement with these major shifts in health care and society, investments in the well-being of nurses will be essential ( ANA, 2015 ) (see Chapter 10 ).

This chapter examines ways in which nurses today work to improve health care equity, as well as their potential future roles and responsibilities in improving equity through efforts to expand access to and improve the quality of health care. Existing exemplars are also described, as well as implications of COVID-19 for health care access and quality.

NURSES’ ROLES IN EXPANDING ACCESS TO QUALITY HEALTH CARE

The United States spends more than $3.5 trillion per year on health care, 25 percent more per capita than the next highest-spending country, and under-performs on nearly every metric ( Emanuel et al., 2020 ). Life expectancy, infant mortality, and maternal mortality are all worse in the United States than in most developed countries. In the United States, moreover, disparities in health care access and health outcomes are seen across racial lines; however, being able to use social and financial capital to buy the best health care is not necessarily associated with the world’s best health outcomes. Even among White U.S. citizens and those of higher socioeconomic status (SES), U.S. health indicators still lag behind those in many other countries ( Emanuel, 2020 ). The U.S. population will not fully thrive unless all individuals can live their healthiest lives, regardless of their income, their race or ethnicity, or where they live. As discussed in Chapter 2 , however, race and ethnicity, income, gender, and geographic location all play substantial roles in a person’s ability to access high-quality, equitable, and affordable health care. A variety of professionals from within and outside of health care settings participate in efforts to ensure equitable access to care. But the role of nurses in these efforts is key, given their interactions with individuals and families in providing and coordinating person-centered care for preventive, acute, and chronic health needs within health settings, collaborating with social services to meet the social needs of individuals, and engaging in broader population and community health through roles in public health and community-based settings.

Both in the United States and globally, the rapid growth in the number of older people in the population will likely lead to increased demand for services and programs to meet their health and social care needs ( Donelan et al., 2019 ; Spetz et al., 2015 ), including care for chronic conditions, which account for approximately 75 percent of all primary care visits ( Zamosky, 2013 ). The aging population will also bring change in the kinds of care the patient population will need. Older people tend to require more expensive care, and to need increasing support in managing multiple conditions and retaining strength and resilience as they age (Pohl et al., 2018). These realities underscore the importance of designing, testing, and adopting chronic care models, in which teams are essential to managing chronic disease, and registered nurses (RNs) play a key role as chronic disease care managers ( Bodenheimer and Mason, 2016 ). Studies of exemplary primary care practices ( Bodenheimer et al., 2015 ; Smolowitz et al., 2015 ) define key domains of RN practice in primary care, including preventive care, chronic illness management, practice operations, care management, and transition care.

Since the passage of the Patient Protection and Affordable Care Act, substantial changes have occurred in the organization and delivery of primary care, emphasizing greater team involvement in care and expansion of the roles of each team member, including RNs ( Flinter et al., 2017 ). Including RNs as team members can increase access to care, improve care quality and coordination for chronic conditions, and reduce burnout among primary care practitioners by expanding primary care capacity ( Fraher et al., 2015 ; Ghorob and Bodenheimer, 2012 ; Lamb et al., 2015 ).

In primary care, RNs can assume

at least four responsibilities: 1) Engaging patients with chronic conditions in behavior change and adjusting medications according to practitioner-written protocols; 2) Leading teams to improve the care and reduce the costs of high-need, high-cost patients; 3) Coordinating the care of chronically ill patients between the primary care home and the surrounding healthcare neighborhood; and 4) Promoting population health, including working with communities to create healthier spaces for people to live, work, learn, and play. ( Bodenheimer and Mason, 2016 , pp. 11–12)

Findings from a 2013 study of The Primary Care Team: Learning from Effective Ambulatory Practices (LEAP) suggest that a large majority of LEAP primary care practices, regardless of practice type or corporate structure, use RNs as a key part of their care team model ( Ladden et al., 2013 ). This contrasts with a study of 496 practices in the Centers for Medicare & Medicaid Services (CMS) Comprehensive Primary Care initiative ( Peikes et al., 2014 ) that found that only 36 percent of practices had RNs on staff, compared with 77 percent of LEAP sites ( Flinter et al., 2017 ).

The health needs of individuals exist across a spectrum, ranging from healthy people, for whom health promotion and disease prevention efforts are most appropriate, to people who have limited functional capacity as a result of disabilities, severe or multiple chronic conditions, or unmet social needs or are nearing the end of life. Access to quality health care services is an important SDOH, and equitable access to care is needed for “promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity” ( ODPHP, 2020 ). Likewise, “strengthening the core of primary care service delivery is key to achieving the Triple Aim of improved patient care experiences, better population health outcomes, and lower health care costs” ( Bodenheimer and Mason, 2016 , p. 23). The 2011 The Future of Nursing report echoes these themes:

while changes in the healthcare system will have profound effects on all providers, this will be undoubtedly true for nurses. Traditional nursing competencies, such as care management and coordination, patient education, public health intervention, and transitional care, are likely to dominate in a reformed healthcare system as it inevitably moves toward an emphasis on prevention and management rather than acute [hospital] care. ( IOM, 2011 , p. 24)

Given the increased evidence supporting the focus on addressing social needs and SDOH to improve health outcomes, these competencies are even more important a decade later. While progress has been made, there is still work to be done, and leveraging and expanding the roles and responsibilities of nurses can help improve access to care ( Campaign for Action, n.d. ).

For people who have difficulty accessing health care because of distance, lack of providers, lack of insurance, or other reasons, nurses are a lifeline to care that meets them where they are. Nurses work in areas that are underserved by other health care providers and serve the uninsured and underinsured. They often engage with and provide care to people in their homes, they work in a variety of clinics, they use telehealth to connect with people, and they establish partnerships and create relationships in schools and communities. In addition to expanding the capacity of primary care, nurses serve in vital roles during natural disasters and public health emergencies, helping to meet the surge in the need for care (see Chapter 8 ). Yet, the potential for nurses to advance health equity through expanded access to care is limited by state and federal laws and regulations that restrict nurses’ ability to provide care to the full extent of their education and training (see Chapter 3 ). Ways in which nurses can fulfill this potential to increase access to care for populations with complex health and social needs are discussed below.

INCREASING ACCESS FOR POPULATIONS WITH COMPLEX HEALTH AND SOCIAL NEEDS

Many individuals cannot access health care because of lack of insurance, inability to pay, and lack of clinics or providers in their geographic area. To bridge this gap, access to care is expanded through a variety of settings where nurses work, including federally qualified health centers (FQHCs), retail clinics, home health and home visiting, telehealth, school nursing, and school-based health centers, as well as nurse-managed health centers. Across all of these settings, nurses are present and facilitate access to health services for individuals and families, often serving as a bridge to social services as well.

Federally Qualified Health Centers

Through FQHCs—outpatient facilities located in a federally designated medically underserved area or serving a medically underserved population—nurses expand access to services for individuals regardless of ability to pay by helping to provide comprehensive primary health care services, referrals, and services that facilitate access to care. The role of advanced practice registered nurses (APRNs) in FQHCs has grown over time ( NACHC, 2019 ). The emerging role of RNs in FQHCs is seen in increased interactions with patients, involvement in care management, and autonomy in the delivery of care. Nurses also work to address key social factors in partnership with care coordinators, health coaches, and social workers to improve health outcomes ( Flinter et al., 2017 ).

Retail Clinics

Health care delivery in the United States has been undergoing transformation, and these changes provide new opportunities for more patients and greater access to nurses as new policies are implemented, new payment models take hold, resources are focused on SDOH, and consumerism shapes care choices. One change in particular since the prior The Future of Nursing report ( IOM, 2011 ) has been and will continue to be impactful for nursing: the emergence of nontraditional health care entities, such as retail clinics. The evolution and rapid growth of these established retail clinics provide increased accessibility of basic care, health screenings, vaccines, and other services for some populations ( Gaur et al., 2019 ). The number of such is growing rapidly, from around 1,800 in 2015 to 2,700 operating in 44 states and the District of Columbia by 2018.

Retail clinics provide more accessible primary care for some populations. In 2016, 58 percent of retail clinic visits represented new utilization instead of substitution for more costly primary care or emergency department visits ( Bachrach and Frohlich, 2016 ). Many individuals and families use retail clinics for their convenience, which includes long hours of operation, accessible location, and walk-in policies, as well as low-cost visits. These attributes are important for those with lower income or without insurance who may not have a regular source of care or be able to access a primary care provider ( Bachrach and Frohlich, 2016 ). However, research shows retail clinics are typically placed in higher-income, urban, and suburban settings with higher concentrations of White and fewer Black and Hispanic residents ( RAND Corporation, 2016 ). The RAND Corporation (2016) study found that while 21 percent of the U.S. population lived in medically underserved areas, only 12.5 percent of retail clinics were located in these areas. RAND concluded that “overall, retail clinics are not improving access to care for the medically underserved.” Thus, while these new models of care have the potential to advance health care equity and population-level health, the available data do not indicate that this potential has been realized ( RAND Corporation, 2016 ). The equity impact of these retail clincs depends in large part on who utilizes the services, and whether the utilization patterns are similar to or different from those of traditional health care.

Retail clinics are staffed largely by nurse practitioners (NPs) ( Carthon et al., 2017 ). These clinics in pharmacies and grocery stores often have been constrained by restrictive scope-of-practice laws. In 2016, a study by the University of Pennsylvania School of Nursing’s Center for Health Outcomes and Policy Research investigated scope-of-practice regulatory environments and retail-based clinic growth. Looking at three states with varying levels of scope-of-practice restrictions, the study found an association between relaxation of practice regulations and retail clinic growth. Evidence suggests that optimization of innovative health care sites such as retail clinics will require moving toward the adoption of policies that standardize the scope of practice for NPs, the providers who largely staff retail clinics ( Carthon et al., 2017 ).

Home Health and Home Visiting

Visiting people in their homes can advance equitable access to quality health care. Home health care has increased access to care for many Americans, from older individuals to medically fragile children. Yao and colleagues (2021) recently explored trends in the U.S. workforce providing home-based medical care and found that less than 1 percent of physicians participating in traditional Medicare provide more than 50 home visits each year (a rate unchanged between 2012 and 2016). By contrast, the number of NPs providing home visits nearly doubled during that same period. Home health nurses address a fragmented system by coordinating care for patients transitioning from a tertiary care facility to ongoing health care within their own homes. Since the onset of the COVID-19 pandemic, these nurses have increasingly provided families with respite for caregivers and offered mental health services in many forms, but certainly in decreasing social isolation for elderly people. Delivering care at home has offered a window for physicians and NPs to see where patients live, to engage in telehealth video calls with family members present, and to see the features of neighborhoods that impact health (e.g., sidewalks, playgrounds, stairs).

With the expansion in the home health care industry driven by an aging population, home visiting nurses are essential to providing care and enhancing health care equity ( Walker, 2019 ). Prior to 2020, Medicare rules allowed only physicians to order home health services for Medicare beneficiaries. However, the Coronavirus Aid, Relief, and Economic Security (CARES) Act permanently authorizes physician assistants and NPs to order home health care services for Medicare patients. In addition, CMS has instituted new policies outlining comprehensive temporary measures for increasing the capacity of the U.S. health care system to provide care to patients outside a traditional hospital setting amid the rising number of COVID-19-related hospitalizations nationwide. These measures include both the Hospital Without Walls and Acute Hospital Care At Home programs, both initiated during the pandemic. Under previous federal requirements, hospitals had to provide services within their own buildings, raising concerns about capacity for treating COVID-19 patients, especially those requiring ventilator and intensive care. Under CMS’s temporary new rules, hospitals can transfer patients to outside facilities, such as ambulatory surgery centers, inpatient rehabilitation hospitals, hotels, and dormitories, while still receiving hospital payments under Medicare. Provision for at-home care, which is often preferred by patients, is especially important during a crisis such as the pandemic, when hospital care means family and/or caregivers cannot be present. Moreover, some research has shown home care to be less costly and to result in fewer readmissions relative to hospital care ( Levine et al., 2020 ). These programs also will create new demand for nurses to work in the community and are the types of adaptations that occurred as a result of the COVID-19 pandemic that should remain permanent to expand high-quality access to care.

The locus of care delivery will continue to follow personal preferences of individuals and families. To improve health care access, nurses will need to be intentional about meeting patients where they are in the most literal sense, and to serve as advocates with and within public health, retail clinics, and health systems to ensure that patients can access the care they need in their homes and neighborhoods. Box 4-1 describes several innovative nurse-led, in-home care programs.

Innovative In-Home Care Programs.

In addition to home health, nurse home visiting programs often include such services as health check-ups, screenings, referrals, and guidance in navigating other programs and services in the community ( Child and Family Research Partnership, 2015 ). Growing evidence suggests that home visits by nurses during pregnancy and in the first years of a child’s life can improve the health and well-being of both child and family, including by promoting maternal and child health, prevention of child abuse and neglect, positive parenting, child development, and school readiness. This positive impact has been found to continue into adolescence and early adulthood ( NASEM, 2019 ).

The proliferation of mobile devices and applications offers an opportunity for nurses to use telehealth more broadly to connect with individuals. Telehealth, including video visits, email, and distance education, serves as a tool to connect with people on an ongoing basis without their having to leave their homes, workplaces, or other settings, and allows for long-distance patient and clinician contact for purposes of clinical interventions, health promotion, education, assessment, and monitoring. The use of telehealth is especially helpful for those who have difficulty traveling to obtain care and those who reside in rural or remote areas. Vulnerable populations with multiple chronic illnesses, poor health literacy, and lack of supportive resources may benefit the most from telehealth use. However, use of telehealth or virtual health tools is limited by access to reliable Internet connections and the availability of the necessary hardware, including smartphones, computers, or webcams. A recent report in the Journal of the American Medical Association looks at 41 FQHCs serving 1.7 million patients. Prior to the COVID-19 pandemic, there was minimal telehealth use at these facilities. During March 2020, FQHCs rapidly substituted in-person visits with telephone and video visits. For primary care, however, 48.5 percent of telehealth visits occured by telephone and 3.4 percent by video. In addition, CMS estimated that 30 percent of telehealth visits were audio-only during the pandemic. These numbers indicate that telehealth appointments for lower-income Americans were in large part audio-only, raising questions about the quality of care ( Uscher-Pines et al., 2021 ).

There have been examples of telehealth activities that have demonstrated great success. The Mississippi Diabetes Telehealth Network, for example, implemented a program that uses telehealth in the home as a viable way to bring a care team to patients to assist them as they manage their illnesses. NPs provide daily health sessions and remote monitoring for individuals with diabetes ( Davis et al., 2020 ; Henderson et al., 2014 ). A prospective, longitudinal cohort study design evaluated the relationship between using telehealth for chronic care management and diabetes outcomes over a 12-month period, finding a significant difference in HbA1c values from baseline to 3-, 6-, 9-, and 12-month values ( Davis et al., 2020 ). In another example, Mercy Hospital, a virtual care center, delivers telehealth services to rural communities in Arkansas, Kansas, Missouri, and Oklahoma. One of its many services is Nurse on Call, which provides timely clinical advice and is available around the clock. In still another example, Banner Health’s skilled nursing model delivers home care combined with telehealth services to people at home instead of their having to move to a nursing home facility ( Roth, 2018 ).

School Nursing

School nurses are front-line health care providers, serving as a bridge between the health care and education systems. Hired by school districts, health departments, or hospitals, school nurses attend to the physical and mental health of students in school. As public health sentinels, they engage school communities, parents, and health care providers to promote wellness and improve health outcomes for children. School nurses are essential to expanding access to quality health care for students, especially in light of the increasing number of students with complex health and social needs. Access to school nurses helps increase health care equity for students. For many children living in or near poverty, the school nurse may be the only health care professional they regularly access.

School nurses treat and help students manage chronic health conditions and disabilities; address injuries and urgent care needs; provide preventive and screening services, health education, immunizations, and psychosocial support; conduct behavioral assessments; and collaborate with health care providers, school staff, and the community to facilitate the holistic care each child needs ( Council on School Health, 2008 ; Holmes et al., 2016 ; HRSA, 2017 ; Lineberry and Ickes, 2015 ; Maughan, 2018 ). By helping students get and stay healthy, school health programs can contribute to closing the achievement gap ( Basch, 2011 ; Maughan, 2018 ). According to Johnson (2017) ,

Healthy children learn better; educated children grow to raise healthier families advancing a stronger, more productive nation for generations to come. School nurses work to assure that children have access to educational opportunities regardless of their state of health. (p. 1)

Meeting the mental health needs of children can be particularly challenging. Researchers estimate that about a quarter of all school-age children and adolescents struggle with mental health issues, such as anxiety and depression. Approximately 30 percent of student health visits to the school nurse are for mental health concerns, often disguised by complaints of headaches and stomachaches ( Foster et al., 2005 ). School nurses have experience with screening students at risk for a variety of such concerns and can assist students in addressing them ( NASN, 2020a ). However, most youth—nearly 80 percent—who need mental health services will not receive them ( Kataoka et al., 2005 ); schools are not always equipped to deal with students’ emotional needs, and parents often lack the awareness or resources to get help for their children. Additionally, a recent study found disparities in access to mental health treatment for students along racial and ethnic lines ( Lipson et al., 2018 ), and structural racism undergirds many risk factors for mental illness (see Chapter 2 ). The COVID-19 pandemic has revealed—and exacerbated—inequities among children of different incomes and races/ethnicities. School closures and social isolation have affected all students, but especially those living in poverty. In addition to the damage to student learning, the loss of access to mental health services that were offered by schools has resulted in the emergence of a mental health crisis ( Leeb et al., 2020 ; Patrick et al., 2020 ; Singh et al., 2020 ).

Schools are increasingly being recognized not just as core educational institutions but also as community-based assets that can be a central component of building healthy and vibrant communities ( NASEM, 2017 ). Accordingly, schools and, by extension, school nurses are being incorporated into strategies for improving health care access, serving as hubs of health promotion and providers of population-based care ( Maughan, 2018 ). Yet, while there have been calls for every school to have access to a nurse ( Council on School Health, 2016 ; NASN, 2020b ), only 39.9 percent of schools employed a full-time nurse in 2017. The remainder of schools (39.3 percent) employed a part-time nurse or did not employ a nurse at all (25.2 percent) ( Willgerodt, 2018 ). The availability and staffing levels of school nurses vary greatly by geography ( Willgerodt, 2018 ) (see Figure 4-1 ).

Licensure staffing patterns (paid and unpaid volunteer) by geography. SOURCE: Data from Willgerodt, 2018.

To address the lack of health care resources in rural school settings, telehealth programs have been implemented with success ( RHI, 2019 ). An example is Health-e-Schools, in which onsite school nurses connect sick students with health care providers. The program employs a full-time, off-site family NP who uses telehealth to evaluate and diagnose patients with such health issues as earaches, sore throats, colds, and rashes, as well as to provide sports physicals, medication, chronic disease management, and behavioral health care. It began as a telehealth program implemented by only 3 schools in 2011 and has since expanded to more than 80 schools serving more than 25,000 students. Health-e-Schools has helped increase classroom attendance and decrease the amount of time parents or guardians must take off from work to bring their children to appointments. This model relies heavily on the school nurses employed within each school district to serve as primary telehealth providers, thus requiring that funding be allocated to provide a school nurse in each school.

School-Based Health Centers

School-based health centers (SBHCs) also make care accessible to students in the school setting. In 2017, 2,584 SBHCs were operating in the United States ( Love et al., 2019 ). SBHCs often operate as a partnership between the school and a community health organization, such as a community health center, hospital, or local health department; more than half are supported by or are an extension of FQHCs ( SBHA, n.d. ). SBHC services include primary care, mental health care, social services, dentistry, and health education, but vary based on community needs and resources as determined through collaborations among the community, the school district, and health care providers ( CPSTF, 2015 ; HRSA, 2017 ). Services are provided by interprofessional teams of health care professionals that include nurses, mental health care providers, physicians, nutritionists, and others. As of 2017, NPs provided primary care services onsite and through telehealth services at 85 percent of SBHCs ( Love et al., 2019 ; SBHA, 2018 ).

One example of an SBHC is the nurse-run Vine School Health Center (VSHC) located at the Vine Middle Magnet School in Knoxville, Tennessee, a Title I school where 100 percent of the students qualify for free lunch. VSHC provides onsite and telehealth services to anyone up to 21 years of age who lives in the county. It also serves 10 other Title I schools through direct health care or telehealth services. The clinic is a partnership between the University of Tennessee College of Nursing and Knox County Schools and is staffed by nurses, nursing students, social workers, and special education professionals. Staff assist families with social needs, including food, housing, clothing, linkages to health insurance, and financial support for rent and utilities ( AAN, 2015 ; Pittman, 2019 ). Services rendered during the 2016–2017 school year included 1,110 early and periodic screening, diagnostic and treatment (EPSDT) exams; 1,896 immunizations; 4,455 physical health visits; and 1,796 mental health clinic visits. VSHC estimates that its services enabled the avoidance of more than 2,500 potential emergency room visits per academic year, associated with savings of about $375,000 per year ( AAN, 2015 ).

IMPROVING THE QUALITY OF HEALTH CARE

Access to comprehensive health care services is a precursor to equitable, quality health care. Nurses are uniquely qualified to help improve the quality of health care by helping people navigate the health care system, providing close monitoring and follow-up across the care continuum, focusing care on the whole person, and providing care that is culturally respectful and appropriate. Nurses can help overcome barriers to quality care, including structural inequities and implicit bias, through care management, person-centered care, and cultural humility.

Care Management

In the current health care system, care is often disjointed, with processes varying between primary and specialty care and between traditional and emerging care sites. People may not understand the processes of the health care system, such as where they will receive care, how to make appointments, or the various providers with whom they may come into contact. Perhaps most important, patients may not understand why all the providers across settings where they receive care should be knowledgeable about the services they receive and the problems that have been identified to ensure seamless, continuous high-quality care. Social factors affecting people with complex health needs may also adversely affect their ability to receive optimal care. Care management, care coordination, and transitional care are activities that nurses perform as members of a health care team to decrease fragmentation, bolster communication, and improve care quality and safety. A care management approach is particularly important for people with complex health and social needs, who may require care from multiple providers, medical follow-up, medication management, and help in addressing their social needs.

Care management—a set of activities designed to “enhance coordination of care, eliminate duplication of services, reduce the need for expensive medical services, and increase patient engagement in self-care”—helps ensure seamless care ( CHCS, 2007 ; Goodell et al., 2009 ). The components of care management include care coordination, transitional care, and social care.

Care coordination is defined as the “deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services.” It is needed both to overcome obstacles of the health care system, such as fragmentation, communication, and billing/cost, and to increase access ( McDonald et al., 2007 , p. 4).

Transitional care entails coordinating care for people moving between various locations or levels of care, providing navigation, coordination, medication reconciliation, and education services ( Storfjell et al., 2017 ). The Transitional Care Model, developed by Mary Naylor (see Box 4-2 ), and the Care Transitions Intervention, developed by Eric Coleman, are prominent nurse-centered care models focused on the often disjointed transition from an inpatient hospital stay to follow-up ambulatory care. Both models engage people with chronic illness from hospitalization to postdischarge, and employ a nursing coach or team “to manage clinical, psychosocial, rehabilitative, nutritional and pharmacy needs; teach or coach people about medications, self-care and symptom recognition and management; and encourage physician appointments” ( Storfjell et al., 2017 , p. 27). Both reduce readmissions and costs ( Storfjell et al., 2017 ).

Transitional Care Model.

Health care delivery models that incorporate social care have created critical roles for nurses in coordinating care across providers and settings and collaborating with other professionals and community resources to improve the health of individuals with complex health and social needs. Chapter 5 provides examples of nurse-centered programs incorporating social care. Nurses are vital to carrying out these functions of care management. Common to nurses’ roles are functions including providing care coordination, developing care plans based on a person’s needs and preferences, educating people and families within care settings and during discharge, and facilitating continuity of care for people across settings and providers ( ANA, n.d. ).

Person-Centered Care

The person-centered care model embraces personal choice and autonomy and customizes care to an individual’s abilities, needs, and preferences ( Kogan et al., 2016 ; Van Haitsma et al., 2014 ). Through person-centered care, nurses collaborate with people, including the patient and other care team members, to deliver personalized quality care that addresses physical, mental, and social needs ( CMS, 2012 ; Terada et al., 2013 ). Features of person-centered care include an emphasis on codesign of interventions, services, and policies that focus on what the person and community want and need; respect for the beliefs and values of people; promotion of antidiscriminatory care; and attention to such issues as race, ethnicity, gender, sexual identity, religion, age, socioeconomic status, and differing ability status ( Santana et al., 2018 ). And person-centered care focuses not only on the individual but also on families and caregivers, as well as prevention and health promotion. Integrating person-centered care that improves patient health literacy is necessary to ensure patient empowerment and engagement and maximize health outcomes. Health literacy ensures that “patients know what they must do after all health care encounters to self-manage their health” ( Loan et al., 2018 , p. 98).

Research has demonstrated the efficacy of person-centered care, for example, in reducing agitation, neuropsychiatric symptoms, and depression, as well as improving quality of life, for individuals with dementia ( Kim and Park, 2017 ). In another example, people with acute coronary syndrome receiving person-centered care reported significantly higher self-efficacy ( Pirhonen et al., 2017 ). Person-centered care is person-directed, such that people are provided with sufficient information to help them in making decisions about their care and increase their level of engagement in care ( Pelzang, 2010 ; Scherger, 2009 ), and nurses who engage people in their care are less likely to make mistakes ( Leiter and Laschinger, 2006 ; Prins et al., 2010 ; Shiparski, 2005 ). Person-centered care leads to better communication between patients and caregivers and improves quality of care, thereby increasing patient satisfaction, care adherence, and care outcomes ( Hochman, 2017 ).

Cultural Humility

As discussed in Chapter 2 , implicit bias can lead to discrimination against others. In particular, structural racism in health care compromises the ability to deliver culturally competent care ( Evans et al., 2020 ).

Historically, nursing has been at the forefront of advocacy, and there are many examples of how nurses have addressed, and are addressing, inequities in many aspects of our teaching, research, scholarship, and practice. Yet, there remain too many examples of structural racism throughout nursing and we must be open to continuing to examine, identify, and change these within our own profession. ( Villaruel and Broome, 2020 , p. 375)

Nurses may contribute to structural inequities in how they facilitate or hamper access to quality health care services since they are frequently the first point of contact for many individuals who need care. Cultural humility—“defined by flexibility; awareness of bias; a lifelong, learning-oriented approach to working with diversity; and a recognition of the role of power in health care interactions” ( Agner, 2020 , p. 1)—is therefore essential for nurses.

Cultural humility enables nurses to participate in more respectful partnerships with patients in order to advance health care equity. According to Foronda and colleagues (2016) , cultural humility has been found to result in effective treatment, decision making, communication, and understanding; better quality of life; and improved care. In contrast, clinicians with implicit bias may show less compassion toward and spend less time and effort with certain patients, leading to adverse assessment and care ( Narayan, 2019 ). Because implicit bias can negatively affect patient interactions and health outcomes, it is important for nurses to be aware of their bias and how it may directly or indirectly impact patient interactions and the quality of care they provide ( Hall et al., 2015 ).

Multiple strategies exist to help nurses achieve cultural humility and manage implicit bias to ensure that they provide high-quality, equitable care. Chapter 7 details the importance of incorporating cultural humility in nursing education. Instead of focusing broadly on the general population, quality improvement interventions characterized by cultural humility focus on needs that are unique to people of color (POC) and tailor care to overcome cultural and linguistic barriers that cause disparities in care (Green et al., 2010). With this approach, data on disparities are used to assess an intervention, with an emphasis on addressing barriers that are specific to underrepresented groups ( ANA, 2018 ; Green et al., 2010; Villarruel and Broome, 2020 ). Box 4-3 describes culturally and linguistically appropriate services, designed to equip nurses with the knowledge, skills, and awareness to provide high-quality care for all patients regardless of cultural or linguistic background.

Culturally and Linguistically Appropriate Services.

When nurses are educated and empowered to act at multiple levels—upstream, midstream, and downstream—they help reduce the effects of structural inequities generated by the health care system. This includes education about how structural inequities may affect their practice environments (as well as research and policy) and, by association, the people with whom they work in clinical and community-based settings (see the detailed discussion of nursing education in Chapter 7 ).

IMPLICATIONS OF COVID-19 FOR HEALTH CARE EQUITY

The COVID-19 pandemic has highlighted the pivotal role of nurses in addressing health care equity. During public health emergencies, nurses in hospitals and in public health and other community settings need to function collaboratively and seamlessly. The pandemic has heightened the need for team-based care, infection control, person-centered care, and other skills that capitalize on the strengths of nurses ( LaFave, 2020 ). Broadening of scope-of-practice regulations and expansion of telehealth services during the COVID-19 pandemic have allowed nurses to practice to the full extent of their education and training, providing equitable care and increasing access to care.

The surge of critically ill people due to the pandemic created the need to rapidly increase the capacity of the health care workforce, especially to replenish workforce members who needed to quarantine or take time to care for sick family members or friends ( Fraher et al., 2020 ). In response, multiple governors issued executive orders expanding the scope of practice for NPs. As of April 10, 2020, five states (Kentucky, Louisiana, New Jersey, New York, and Wisconsin) had temporarily suspended all practice agreement requirements, providing NPs with full practice authority ( AANP, 2020 ). Thirteen states (Alabama, Arkansas, Indiana, Massachusetts, Michigan, Mississippi, Missouri, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, and West Virginia) had enacted a temporary waiver of selected practice agreement requirements. By December 7, 2020, executive orders had expired for Kansas, Michigan, and Tennessee, and all practice agreement requirements had been temporarily suspended for Kentucky, Louisiana, New Jersey, New York, Virginia, and Wisconsin ( AANP, 2020 ). Maintaining these broadened scopes of practice for nurses after the pandemic has ended would increase NPs’ opportunities to increase access to quality health care for individuals with complex health and social needs.

Hospitals are also redeploying health care workers—physicians, NPs, nurses, and others—from areas with decreasing patient volumes (resulting from, for example, limitations on elective procedures) to higher-need intensive care unit (ICU), acute care, and emergency service areas. For example, nurse anesthetists have been redeployed from operating rooms to ICUs to intubate and place central lines for patients in the surge response to COVID-19 ( Brickman et al., 2020 ). As of December 2020, CMS was finalizing changes that allow NPs to “supervise the performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians” ( CMS, 2020a ). These changes will help make permanent some of the workforce flexibilities that were allowed during the pandemic.

Although much attention has been paid to the dire need for health care supplies and hospital beds to treat patients with severe cases of COVID-19, less attention has been directed at impacts of the pandemic on communities; their ability to weather the crisis; and individuals’ physical, mental, and social health. Nurses, including public health nurses, working in and with communities continue to be critical to efforts to contain the COVID-19 pandemic, as well as other pandemics that may occur in the future.

Older Adults

Older adults have been disproportionately affected by COVID-19, and older POC are even more likely to experience disproportionate morbidity and mortality. CMS data show that Black Medicare beneficiaries were hospitalized four times as often and contracted the virus nearly three times as often compared with Whites of similar age ( CMS, 2020b ; Godoy, 2020 ). According to the Centers for Disease Control and Prevention (CDC), 8 of 10 deaths from COVID-19 in the United States have been among adults 65 and older ( Freed et al., 2020 ). Nursing homes have been particularly hard hit and faced multiple unique challenges in serving those most vulnerable to the virus.

The pandemic has had significant emotional, social, and mental health effects on older adults and their caregivers, and nurses and nursing assistants in nursing homes have borne a great burden in carrying out the front-line work of trying to keep residents healthy, care for recovered patients, and help mitigate isolation and its detrimental effects on residents. These tasks in many cases have been performed in the absence of residents’ family members and friends, who have not been allowed to visit as part of efforts to prevent the spread of infection. Inside nursing homes, the nursing staff have had to act as both caregivers and confidants, carrying out their usual tasks while also supporting many residents through confusion, depression, and suicidal ideation. In multigenerational homes, additional steps have been required to mitigate COVID-19 risk for older adults, such as using separate bathrooms, wearing masks within the household if someone is sick, or avoiding visitors. Demand for home health nursing services, inclusive of following strict public health measures (masks, handwashing, quarantining), has increased during the pandemic.

Changes in Medicare policy during the COVID-19 pandemic have given older adults greater access to a variety of mental health services, including those provided in their homes. Access to telehealth has also been expanded to meet the urgent need to provide safe access to care. Medicare payment for telehealth visits in nursing homes was previously restricted to rural areas, but under the 1135 waiver and the Coronavirus Preparedness and Response Supplemental Appropriations Act, CMS temporarily broadened access to telehealth services to ensure that Medicare beneficiaries could access services from the safety of their homes ( CMS, 2020b ). Accordingly, NPs and other health care professionals have used telehealth to screen people for COVID-19 and treat noncritical illnesses that can be managed at home.

Telehealth also has helped address concerns about workforce capacity for adult health care due to the surging numbers of COVID-19 cases and reports of exposure among health care workers: “as many as 100 health care workers at a single institution have to be quarantined at home because of COVID-19” ( Hollander and Carr, 2020 ). NPs who are quarantined because of exposure can provide telehealth services. It is important to note that the barriers discussed earlier due to restrictive scope-of-practice regulations may include limitations on providing telehealth services across state lines. Recognition of clinical licenses across states, such as through interstate agreements, could ease these barriers ( NQF, 2020 ).

Although CDC has reported that COVID-19 poses a relatively low risk for children, research on natural disasters has shown that, compared with adults, children are more vulnerable to the emotional impact of traumatic events that disrupt their daily lives. The pandemic has required that children make significant adjustments to their routines (e.g., because of school and child care closures and the need for social distancing and home confinement), disruptions that may interfere with a child’s sense of structure, predictability, and security. Young people—even infants and toddlers—are keen observers of people and environments, and they notice and react to stress in their parents and other caregivers, peers, and community members ( Bartlett et al., 2020 ). While most children eventually return to their typical functioning when they receive consistent support from sensitive and responsive caregivers, others are at risk of developing significant mental health problems, including trauma-related stress, anxiety, and depression. Children with prior trauma or preexisting mental, physical, or developmental problems, as well as those whose parents struggle with mental health disorders, substance misuse, or economic instability, are at especially high risk for emotional disturbance. Thus, in addition to keeping children physically safe during a public health emergency such as the COVID-19 pandemic, it is important to care for their emotional health ( Bartlett et al., 2020 ).

Barriers to mental health care result in serious immediate and long-term disadvantages for young people, especially students of color. Mental health—a key component of children’s healthy development—was already a growing concern prior to the pandemic and the concurrent nationwide protests in response to racial injustice and anti-Black racism, with the demand for mental health services among U.S. adolescents increasing in the past decade ( Mojtabai et al., 2020 ). This concern has been fueled by increases in the incidence of anxiety and depression, as well as a trend in which victims of suicide have been younger. As noted earlier, programs such as Nurse-Family Partnership (see Box 4-1 ), as well as school nurses and school-based health centers, represent channels through which nurses can assist children and families with health care access to address mental health needs.

The health care system is being transformed by an increased focus on community-based coordinated care and the use of technology to improve communication so as to achieve better population health outcomes at lower cost. At the local level, providers in public health and school settings can collaborate strategically to increase their community’s capacity to address the root causes of illness and improve overall population health by implementing broad social, cultural, and economic reforms that address SDOH. Such collaboration can benefit the entire health care system by leading to seamless care, reducing duplicative services, and lowering the costs of care.

CONCLUSIONS

Whether in an elementary school, a hospital, or a community health clinic, nurses work to address the root causes of poor health. As the largest and consistently most trusted members of the health care workforce, nurses practice in a wide range of settings. They have the ability to manage as well as collaborate within teams and connect clinical care, public health, and social services while building trust with communities. However, nurses are limited in realizing this potential by state and federal laws that prohibit them from working to the full extent of their education and training. The COVID-19 pandemic in particular has revealed that the United States needs to do a much better job of linking health and health care to social and economic needs, and nurses are well positioned to build that bridge.

Conclusion 4-1: Nurses have substantial and often untapped expertise to help individuals and communities access high-quality health care, particularly in providing care for people in underserved rural and urban areas. Improved telehealth technology and payment systems have the potential to increase access, allowing patients to obtain their care in their homes and neighborhoods. However, the ability of nurses to practice fully in these and other settings is limited by state and federal laws that prohibit them from working to the full extent of their education and training. Conclusion 4-2: Nurses are uniquely qualified to improve the quality of health care by helping people navigate the health care system; providing close monitoring, coordination, and follow-up across the care continuum; focusing care on the whole person; and providing care that is culturally respectful and appropriate. Through a team-based approach, nurses can partner with professionals and community members to lead and manage teams and connect clinical care, public health, and social services while building trust with communities and individuals.

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Cite this Page National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11. 4, The Role of Nurses in Improving Health Care Access and Quality.
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Academic essays part 1: the importance of academic writing.

John Fowler

Educational Consultant, explores how to survive your nursing career

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John Fowler, Educational Consultant, explores academic writing

How confident are you in your ability to write academic essays? If you are a student nurse in your first year of training then your answer will depend largely on your previous success, or not, in GCSEs, A levels and the equivalent. If you entered nursing via an alternative route that had less emphasis on traditional academic preparation, then your confidence in writing an essay that draws on referenced literature will probably be much reduced. Even if you were quite strong at school or college work, you may find the transition to self-directed degree study quite difficult. If you are a qualified nurse with a pre-registration diploma or degree, returning to university study to complete a post-registration master's degree, you may still have reservations about your ability to re-engage with academic writing. If you are confident of your ability to communicate nursing theory and its application to clinical care, then this series of articles is probably not for you! However, my experience of teaching nurses, from first-year students to specialist nurses undertaking PhDs, is that very few are confident in their academic writing skills.

Academic ability versus academic writing

For most nurses who struggle with academic skills, it is usually not their innate academic ability that is the problem, but the lack of specific skills required to research the question and then communicate valid findings in a reliable way. For student nurses, this is about understanding where the body of nursing knowledge lies, be that the literature, protocols or clinical practice, how to access it and then communicate those findings. For the experienced nurse undertaking a post-registration degree, it is about dusting off library skills, getting to grips with different IT, exploring the knowledge base relevant to, but outside, pure nursing, understanding the relevance and use of clinical experience and, finally, mastering the skills of writing a long essay that communicates knowledge, experience and innovative ideas.

What ‘sister says’

When I trained as a nurse, it was in pre-university and pre-diploma or degree days; the ward sister or the medical consultant was the source of knowledge. Students quickly learned to develop their nursing skills according to what ‘sister says’: ward sisters and ward routines were the source of knowledge and authority. As nursing research and evidence-based protocols developed and began to inform nursing practice in the 1980s, the source of knowledge moved away from this and included ‘what the literature says’. Nurse training was underpinned at diploma level, validated by a university system that stressed the importance of referencing published materials as the source of authority. As the scientific base and the wealth of nursing-related literature increased over the next 20 years, student nurses were required not just to refer to the literature, but to demonstrate their discussion and critical review of a body of knowledge based on valid and robust evidence; this was reflected in the move to make nursing an all-graduate profession in the early 2010s. In what ways has this transition from ‘sister says’ to the ‘literature says’ changed the way we inform our practice?

Has our ability to apply knowledge to clinical practice changed?

To inform clinical practice and develop clinical expertise, a nurse needs to take various aspects of evidence, evaluate its appropriateness and then apply it to a specific patient or clinical situation. This was true when I was a student nurse and the source of knowledge was the ward sister. It is equally true today when the source of knowledge is more literature-based. What has changed is the origin of the knowledge. In my student days it was probably 85% ward sister and 15% text books. Today it is more like 40% clinical staff and 60% evidenced-based literature. To inform clinical practice, we need to assess the validity and reliability of the knowledge, both clinical- and literature-based, evaluate it and then apply it to clinical care. The difficulty that nursing has over the pure biological science healthcare professions, such as pharmacy and medical sciences, is that a significant proportion of nursing practice draws from the social sciences concerned with feelings and interactions. When a patient is in pain, we know we can draw upon the science of pharmacology and pain administration protocols, but it is only our observation of experienced staff and our own experiential learning that guides us as to when to hold a hand, sit by the bedside or ask about the patient's worries regarding family or pets. Communicating this interaction of hard biological science, evidence-based protocols and the application of softer caring skills is a difficult, yet important, part of academic writing for the nurse. How do we write an essay that justifies the possible benefits of holding a patient's hand, when there are no randomised controlled trials to support its application?

This forthcoming series will explore all the practicalities of planning an essay, managing the literature, developing structure and content, but it will not lose sight of this important principle of incorporating holistic clinical nursing care into academic writing.

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The Importance of Mentorship through your Nursing Degree and Career

Whether you are looking to jumpstart your nursing career or are well into your nursing career, mentorship is key to your success, says Dr. Danielle McCamey, Assistant Dean for Strategic Partnerships. With the vast career opportunities available within nursing, discussing your passions and goals with a mentor can help align your next steps into an academic program, professional role, or even involvement in professional organizations.

Dr. McCamey reminisces on her first mentor, Dr. Sandra Davis, mentioning them to be paramount to her success. She continues to discuss how they taught her about balance within their professional and personal lives. Mentors play an active role in one’s daily success; coaching is provided through a lens and perspective of “what’s next.”

You may find yourself wondering where to start looking for a mentor. Dr. McCamey mentions a few tips in our Admissions Workshop: The Importance of Mentorship through your Nursing Degree and Career to navigating this process. Start by looking at what’s next and consider individuals who may have an interest in this specific specialty/population or have completed an academic program similar to the one you are considering. Or you may look into individuals who are actively leading within departments or professional organizations you may have a future interest in. You may even consider alignment to the impact and legacy you aspire to leave on your patient population through your professional work. Dr. McCamey and Alexander Murphy, Assistant Director for Diversity Initiatives and Healthcare Organizational Leadership Recruitment, discuss the importance of connecting with individuals who have similar lived experiences, such as being a first-generation college student. Dr. McCamey mentions craving a space where she saw individuals who had a similar interest in becoming a doctoral prepared nurse and also looked like her. This was the igniting passion for founding DNPs of Color, which focuses on serving DNPs of Color through networking, mentorship and advocacy to increase diversity in doctoral studies, clinical practice and leadership.

As you meet with your mentor and contemplate your “what’s next,” advancement in your nursing career through academia may very well be the next step. Be intentional about your goals and how you envision yourself advancing the nursing profession through scholarly work or clinical practice. Continue to challenge yourself through academic progression to impact how healthcare is equitably delivered to patients.

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Admissions Talks is a series by the admissions team at Johns Hopkins School of Nursing. Hopkins nurses are full partners and leaders in the health care process, and their role in patient care is unmatched. The admissions team is here to offer advice and guidance on how to be a competitive applicant.

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About The Author: Laura Panozzo

Laura Panozzo is the Assistant Director for DNP Executive, PhD, and DNP/PHD Recruitment at Johns Hopkins School of Nursing. She can help you take the next step in your nursing career, contact her at 443-287-7430 or [email protected] .

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Published: 28 March 2024

Nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care to nursing home residents– a qualitative study

Rachel Gilbert 1 &
Daniela Lillekroken ORCID: orcid.org/0000-0002-7463-8977 1

BMC Nursing volume 23 , Article number: 216 ( 2024 ) Cite this article

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Over the years, caring has been explained in various ways, thus presenting various meanings to different people. Caring is central to nursing discipline and care ethics have always had an important place in nursing ethics discussions. In the literature, Joan Tronto’s theory of ethics of care is mostly discussed at the personal level, but there are still a few studies that address its influence on caring within the nursing context, especially during the provision of end-of-life care. This study aims to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

This study has a qualitative descriptive design. Data were collected by conducting five individual interviews and one focus group during a seven-month period between April 2022 and September 2022. Nine nurses employed at four Norwegian nursing homes were the participants in this study. Data were analysed by employing a qualitative deductive content analysis method.

The content analysis generated five categories that were labelled similar to Tronto’s five phases of the care process: (i) caring about, (ii) caring for, (iii) care giving, (iv) care receiving and (v) caring with. The findings revealed that nurses’ autonomy more or less influences the decision-making care process at all five phases, demonstrating that the Tronto’s theory contributes to greater reflectiveness around what may constitute ‘good’ end-of-life care.

Conclusions

Tronto’s care ethics is useful for understanding end-of-life care practice in nursing homes. Tronto’s care ethics provides a framework for an in-depth analysis of the asymmetric relationships that may or may not exist between nurses and nursing home residents and their next-of-kin. This can help nurses see and understand the moral dimension of end-of-life care provided to nursing home residents during their final days. Moreover, it helps handle moral responsibility around end-of-life care issues, providing a more complex picture of what ‘good’ end-of-life care should be.

Peer Review reports

In recent decades, improving end-of-life care has become a global priority [ 1 ]. The proportion of older residents dying in nursing homes is rising across the world [ 2 ], resulting in a significant need to improve the quality of end-of-life care provided to residents. Therefore, throughout the world, nursing homes are becoming increasingly important as end-of-life care facilities [ 3 ]. As the largest professional group in healthcare [ 4 ], nurses primarily engage in direct care activities [ 5 ] and patient communication [ 6 ] positioning them in close proximity to patients. This proximity affords them the opportunity to serve as information brokers and mediators in end-of-life decision-making [ 7 ]. They also develop trusting relationships with residents and their next-of-kin, relationships that may be beneficial for the assessment of residents and their next-of-kin’s needs [ 8 ]. Moreover, nurses have the opportunity to gain a unique perspective that allows them to become aware of if and when a resident is not responding to a treatment [ 9 ].

When caring for residents in their critical end-of-life stage, nurses form a direct and intense bond with the resident’s next-of-kin, hence nurses become central to end-of-life care provision and decision-making in nursing homes [ 10 ]. The degree of residents and their next-of-kin involvement in the decision-making process in practice remains a question [ 11 ]. Results from a study conducted in six European countries [ 12 ], demonstrate that, in long-term care facilities, too many care providers are often involved, resulting in difficulties in reaching a consensus in care. Although nurses believe that their involvement is beneficial to residents and families, there is a need for more empirical evidence of these benefits at the end-of-life stage. However, the question of who should be responsible for making decisions is still difficult to answer [ 13 ]. One study exploring nurse’s involvement in end-of-life decisions revealed that nurses experience ethical problems and uncertainty about the end-of-life care needs of residents [ 14 ]. Another study [ 10 ] reported patients being hesitant to discuss end-of‐life issues with their next-of-kin, resulting in nurses taking over; thus, discussing end-of-life issues became their responsibility. A study conducted in several nursing homes from the UK demonstrated that ethical issues associated with palliative care occurred most frequently during decision-making, causing greater distress among care providers [ 15 ].

Previous research has revealed that there are some conflicts over end-of-life care that consume nurses’ time and attention at the resident’s end-of-life period [ 16 ]. The findings from a meta-synthesis presenting nurses’ perspectives dealing with ethical dilemmas and ethical problems in end-of-life care revealed that nurses are deeply involved with patients as human beings and display an inner responsibility to fight for their best interests and wishes in end-of-life care [ 17 ].

Within the Norwegian context, several studies have explored nurses’ experiences with ethical dilemmas when providing end-of-life care in nursing homes. One study describing nurses’ ethical dilemmas concerning limitation of life-prolonging treatment suggested that there are several disagreements between the next-of-kin’s wishes and what the resident may want or between the wishes of the next-of-kin and what the staff consider to be right [ 18 ]. Another study revealed that nurses provide ‘more of everything’ and ‘are left to dealing with everything on their own’ during the end-of-life care process [ 19 ] (p.13) . Several studies aiming to explore end-of-life decision-making in nursing homes revealed that nurses experience challenges in protecting the patient’s autonomy regarding issues of life-prolonging treatment, hydration, nutrition and hospitalisation [ 20 , 21 , 22 ]. Other studies conducted in the same context have described that nurses perceive ethical problems as a burden and as barriers to decision-making in end-of-life care [ 8 , 23 ].

Nursing, as a practice, is fundamentally grounded in moral values. The nurse-patient relationship, central to nursing care provision, holds ethical importance and significance. It is crucial to recognise that the context within which nurses practice can both shape and be shaped by nursing’s moral values. These values collectively constitute what can be termed the ethical dimension of nursing [ 24 ]. Nursing ethos and practices are rooted in ethical values and principles; therefore, one of the position statements of the International Council of Nurses [ 25 ] refers to nurses’ role in providing care to dying patients and their families as an inherent part of the International Classification for Nursing Practice [ 26 ] (e.g., dignity, autonomy, privacy and dignified dying). Furthermore, ethical competence is recognised as an essential element of nursing practice [ 27 ], and it should be considered from the following viewpoints: ethical decision-making, ethical sensitivity, ethical knowledge and ethical reflection.

The term ‘end-of-life care’ is often used interchangeably with various terms such as terminal care, hospice care, or palliative care. End-of life care is defined as care ‘to assist persons who are facing imminent or distant death to have the best quality of life possible till the end of their life regardless of their medical diagnosis, health conditions, or ages’ [ 28 ] (p.613) . From this perspective, professional autonomy is an important feature of nurses’ professionalism [ 29 ]. Professional autonomy can be defined based on two elements: independence in decision-making and the ability to use competence, which is underpinned by three themes: shared leadership, professional skills, inter- and intraprofessional collaboration and a healthy work environment [ 30 ].

As presented earlier, research studies have reported that nurses experience a range of difficulties or shortcomings during the decision-making process; therefore, autonomous practice is essential for safe and quality care [ 31 ]. Moreover, autonomous practice is particularly important for the moral dimension in end-of-life care, where nurses may need to assume more responsibility in the sense of defining and giving support to matters that are at risk of not respecting ethical principles or fulfilling their ethical, legal and professional duties towards the residents they care for.

To the best of the researchers’ knowledge, little is known about nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents; therefore, the aim of this study is to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

Theoretical framework

Joan Tronto is an American political philosopher and one of the most influential care ethicists. Her theory of the ethics of care [ 32 , 33 , 34 ] has been chosen as the present study’s theoretical framework. The ethics of care is a feminist-based ethical theory, focusing on caring as a moral attitude and a sensitive and supportive response of the nurse to the situation and circumstances of a vulnerable human being who is in need of help [ 33 , 34 , 35 ]. In this sense, nurses’ caring behaviour has the character of a means—helping to reach the goal of nursing practice—which here entails providing competent end-of-life care.

Thinking about the process of care, in her early works [ 32 , 33 , 34 ], Tronto proposes four different phases of caring and four elements of care. Although the phases may be interchangeable and often overlap with each other, the elements of care are fundamental to demonstrate caring. The phases of caring involve cognitive, emotional and action strategies.

The first phase of caring is caring about , which involves the nurse’s recognition of being in need of care and includes concern, worry about someone or something. In this phase, the element of care is attentiveness, which entails the detection of the patient and/or family need.

The second phase is caring for , which implies nurses taking responsibility for the caring process. In this phase, responsibility is the element of care and requires nurses to take responsibility to meet a need that has been identified.

The third phase is care giving , which encompasses the actual physical work of providing care and requires direct engagement with care. The element of care in this phase is competence, which involves nurses having the knowledge, skills and values necessary to meet the goals of care.

The fourth phase is care receiving , which involves an evaluation of how well the care giving meets the caring needs. In this phase, responsiveness is the element of care and requires the nurse to assess whether the care provided has met the patient/next-of-kin care needs. This phase helps preserve the patient–nurse relationship, which is a distinctive aspect of the ethics of care [ 36 ].

In 2013, Tronto [ 35 ] updated the ethics of care by adding a fifth phase of caring— caring with —which is the common thread weaving among the four phases. When care is responded to through care receiving and new needs are identified, nurses return to the first phase and begin again. The care elements in this phase are trust and solidarity. Within a healthcare context, trust builds as patients and nurses realise that they can rely on each other to participate in their care and care activities. Solidarity occurs when patients, next-of-kin, nurses and others (i.e., ward leaders, institutional management) engage in these processes of care together rather than alone.

To the best of our knowledge, these five phases of caring and their elements of caring have never been interpreted within the context of end-of-life care. The ethics of care framework offers a context-specific way of understanding how nurses’ professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents, revealing similarities with Tronto’s five phases, which has motivated choosing her theory.

Aim of the study

The present study aims to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

The current study has a qualitative descriptive design using five individual interviews and one focus group to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

Setting and participants

The setting for the study was four nursing homes located in different municipalities from the South-Eastern region of Norway. Nursing homes in Norway are usually public assisted living facilities and offer all-inclusive accommodation to dependent individuals on a temporary or permanent basis [ 37 ]. The provision of care in the Norwegian nursing homes is regulated by the ‘Regulation of Quality of Care’ [ 38 ], aiming to improve nursing home residents’ quality of life by offering quality care that meets residents’ fundamental physiological and psychosocial needs and to support their individual autonomy through the provision of daily nursing care and activities tailored to their specific needs, and, when the time comes, a dignified end-of-life care in safe milieu.

End-of-life care is usually planned and provided by nurses having a post graduate diploma in either palliative nursing or oncology nursing– often holding an expert role, hence ensuring that the provision of end-of-life care meets the quality criteria and the resident’s needs and preferences [ 39 ].

To obtain rich information to answer the research question, it was important to involve participants familiar with the topic of study and who had experience working in nursing homes and providing end-of-life care to residents; therefore, a purposive sample was chosen. In this study, a heterogeneous sampling was employed, which involved including participants from different nursing homes with varying lengths of employment and diverse experiences in providing end-of-life care to residents. This approach was chosen to gather data rich in information [ 40 ]. Furthermore, when recruiting participants, the first author was guided by Malterud et al.’s [ 41 ] pragmatic principle, suggesting that the more ‘information power’ the participants provided, the smaller the sample size needed to be, and vice versa. Therefore, the sample size was not determined by saturation but instead by the number of participants who agreed to participate. However, participants were chosen because they had particular characteristics such as experience and roles which would enable understanding how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents.

The inclusion criteria for the participants were as follows: (i) to be a registered nurse, (ii) had a minimum work experience of two years employed at a nursing home, and (iii) had clinical experience with end-of-life/palliative care. To recruit participants, the first author sent a formal application with information about the study to four nursing homes. After approval had been given, the participants were asked and recruited by the leadership from each nursing home. The participants were then contacted by the first author by e-mail and scheduled a time for meeting and conducting the interviews.

Ten nurses from four different nursing homes were invited to participate, but only nine agreed. The participants were all women, aged between 27 and 65 and their work experience ranged from 4 to 21 years. Two participants had specialist education in palliative care, and one was currently engaged in a master’s degree in nursing science. Characteristics of the participants are presented in Table 1 :

Data collection methods

Data were collected through five semistructured individual and one focus group interviews. Both authors conducted the interviews together. The study was carried out between April and September 2022. Due to the insecurity related to the situation caused by the post-SARS-CoV-2 virus pandemic and concerns about potential new social distancing regulations imposed by the Norwegian government, four participants from the same nursing home opted for a focus group interview format. This decision was motivated by a desire to mitigate the potential negative impact that distancing regulations might have on data collection. The interviews were guided by an interview guide developed after reviewing relevant literature on end-of-life care and ethical dilemmas. The development of the interview guide consisted of five phases: (i) identifying the prerequisites for using semi-structured interviews; (ii) retrieving and using previous knowledge; (iii) formulating the preliminary semi-structured interview guide; (iv) pilot testing the interview guide; and (v) presenting the complete semistructured interview guide [ 42 ]. The interview guide was developed by both authors prior to the onset of the project and consisted of two demographic questions and eight main open-ended questions. The interview guide underwent initial testing with a colleague employed at the same nursing home as the first author. After the pilot phase in phase four, minor language revisions were made to specific questions to bolster the credibility of the interview process and ensure the collection of comprehensive and accurate data. The same interview guide was used to conduct individual interviews and focus group (Table 2 ).

The interviews were all conducted in a quiet room at a nursing home. Each interview lasted between 30 and 60 min and were digitally recorded. The individual interviews were transcribed verbatim by the first author. The focus group interview was transcribed by the second author.

Ethical perspectives

Prior to the onset of the data collection, ethical approval and permission to conduct the study were sought from the Norwegian Agency for Shared Services in Education and Research (Sikt/Ref. number 360,657) and from each leader of the nursing home. The study was conducted in accordance with the principles of the Declaration of Helsinki of the World Medical Association [ 43 ]: informed consent, consequences and confidentiality. The participants received written information about the aim of the study, how the researcher would ensure their confidentiality and, if they chose to withdraw from the study, their withdrawal would not have any negative consequences for their employment at nursing homes. Data were anonymised, and the digital records of the interviews were stored safely on a password-protected personal computer. The transcripts were stored in a locked cabinet in accordance with the existing rules and regulations for research data storage at Oslo Metropolitan University. The participants did not receive any financial or other benefits from participating in the study. Written consent was obtained prior to data collection, but verbal consent was also provided before each interview. None of the participants withdrew from the study.

Data analysis

The data were analysed by employing a qualitative deductive content analysis, as described by Kyngäs and Kaakinen [ 44 ]. Both researchers independently conducted the data analysis manually. The empirical data consisted of 63 pages (34,727 words) of transcripts from both individual and focus group interviews. The deductive content analysis was performed in three steps: (i) preparation, (ii) organisation and (iii) reporting of the results.

During the first step—preparation—each researcher, individually, read the transcripts several times to get an overview of the data and select units of analysis by searching for recurring codes and meanings and to carefully compare the similarities and differences between coded data. These codes were labelled independently by both researchers and placed into an analysis matrix.

During the next step—organisation—the researchers met and discussed and then compared and revised the labels several times until they agreed about the preliminary findings. During the interpretative process towards developing an understanding of the empirical data, the content of the labels referred to nurses’ perceptions about how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents, revealing similarities with the five phases of Tronto’s theory of ethics of care [ 32 , 33 ], thus assigning them to the five phases of the theory. Following this final refinement, one main category and five categories, each supported by several subcategories, were identified, as presented in Table 3 .

Reporting the results was the last step in the analysis. To enhance the understanding of the study’s findings, the findings are presented with supporting excerpts from the participants.

In qualitative studies, trustworthiness is the main parameter for appraising the rigour of the study [ 45 ]. To enhance the trustworthiness of the study, four criteria—credibility, transferability, dependability and confirmability, as described by Lincoln and Guba [ 46 ]—were applied.

To support credibility, a detailed description of the sample and the sampling process was provided. Furthermore, the interview guide and the questions that the participants were asked during the interviews are made available to the readers. Moreover, although the data were collected from five individual interviews and one focus group, triangulation of two data collection methods allowed researchers to ensure that the study is based on diverse perceptions and experiences, strengthening the credibility and impact of the study’s findings [ 47 ].

Detailed information about the sample and setting supports the assessment of the transferability of the findings. In this way, the readers can recognise and evaluate whether the findings would be applicable to similar contexts with a similar sample. Quotes from the participants’ statements are given to support the findings. Each quote ends with a number representing the code that each nurse was given before conducting the interviews (i.e., Participant in interview 1, PI1 or participant 6 in focus group interview, P6FG).

To increase dependability, the same interview guide was used to ask all participants the same questions. Dependability was also increased by the researchers reading and analysing the interviews independently and then checking the consistency of the data analysis technique with each other and discussing the analytical process until a consensus was reached.

To enhance confirmability, excerpts from the participants’ statements were included when presenting the findings, thus verifying the concordance of findings with the raw data. This demonstrates that the data were not based on preconceived notions.

Trustworthiness was also supported by member checking, meaning that the researchers sent the participants the transcripts of the interviews immediately after data collection; then, the interviews were transcribed. The participants were asked to review the transcripts and check the accuracy of the data; hence, they had the opportunity to add, remove or clarify their statements. Only one participant answered this request, stating that the transcripts were accurate, and she did not have any further comments. Despite encountering a suboptimal response from participants, the authors remain confident in the trustworthiness of the study. Rich data, derived from a combination of individual and focus group interviews, yielded diverse and nuanced responses from participants, reinforcing the credibility of the findings.

Reflexivity is the researcher’s reflection on their position during the research process [ 48 ]. Both researchers have clinical experience in providing end-of-life care to nursing home residents. Therefore, it was critical to be aware of the impact that their clinical backgrounds might have on the research process from information seeking during the analysis of data and discussion of the findings. To avoid early interpretation of the data, the researchers were aware of their preunderstanding and tried to put it on hold. Both authors engaged in discussions regarding apprehensions and reflections, actively participating in the triangulation process throughout the study to prevent potential bias during data collection, analysis, and interpretation. The theoretical framework was brought in the end of the analysis process, which helped label the emerged findings.

The analysis of the empirical data combined with an ethical reflection helped researchers to identify and understand the moral dimension of nurses’ experiences with end-of-life care provided to nursing home residents. During the analysis, an overarching category emerged– ‘The moral dimension of the provision of end-of life care’– describing nurses’ perceptions about how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents. The participants agreed that end-of-life care is a care process that undergoes several phases, with each phase having its own ethical quality or its own element of care, here according to Tronto’s moral qualities [ 34 ]. In the following section, the findings are described using Tronto’s identified moral qualities for each of the five phases of the care process [ 32 , 33 , 34 , 35 ].

Caring about—being attentive

For the participants, being autonomous was perceived as a feature that increased their awareness of the resident’s caring needs during their last days of life. The participants agreed that the caring process involves paying attention, listening and recognising residents’ unspoken needs. Moreover, it implies nurses being able to make autonomous decisions when deciding which needs to care about at one particular moment.

The participants agreed that the core values of providing end-of-life care were to alleviate suffering, maintain dignity and provide comfort care. The participants perceived caring about as having sufficient knowledge, along with the experience and autonomy in practice, as well as providing comprehensive end-of-life care for residents. For the participants, caring about during the end-of-life process means them being present and dedicated. This implies nurses carefully observing, autonomously acting, and making decisions based on their judgements, and thus, they can decide and choose their course of action promptly based on resident’s condition or side effects. Moreover, caring about involved participants being attentive to perceiving the residents’ needs when the residents could no longer articulate themselves. The participants expressed their worries about resident’s bodily deterioration, leading them to lose their ability to express needs, as shown by the following quote:

There is not much communication when residents go into their last stage of life. Well… some of them are consciously until their death, but most are sedated; therefore, it is necessary to use your knowledge and experience to assess not only their needs for food and liquids or bodily hygiene, but also, we have to monitor their response to pain killers and other medication, and if it’s too much or too little, we need to do what’s needed to reduce or increase the medication and not let them suffer (PI3).

Some of the participants expressed that attentiveness to the residents’ care needs was a skill based on their clinical gaze developed during their careers. Other participants discussed that building a close relationship with the residents while they still could walk and talk was a precondition that helped them develop a clinical gaze, hence facilitating the nurses’ being attentive. Attentiveness allowed the participants to do what was needed when knowing the residents’ needs during the provision of end-of-life care. This may be interpreted as the moral or ethical quality of caring about during the end-of-life caring process, as demonstrated by the following statement:

We have time to know the resident before their health condition worsens… We previously knew what they wanted and how they wanted… their stay at nursing home gives us the opportunity to know their preferences and needs. Morally, we are obliged to provide the same quality of care they received when they could express themselves (PI4).

Caring for—taking responsibility

According to several participants, another phase within the end-of-life caring process was taking responsibility to care for. The participants agreed that monitoring the residents in their last days implies assuming responsibility. Assuming responsibility was perceived as an autonomous caring activity. They also discussed taking this responsibility seriously, which is a moral dimension of the end-of-life caring process and, ultimately, of the nursing profession. Usually, this responsibility was taken by a nurse, but it also involved other healthcare personnel or even next-of-kin. Among these responsibilities, the participants mentioned that the end-of-life caring process included not only caring for the resident’s physiological and psychosocial needs, but also assigning permanent healthcare personnel to continuously monitor the resident. Although the participants were aware that they share responsibilities for the caring process, ‘who does what…’, they ultimately had the overall responsibility for the whole end-of-life caring process.

Another responsibility included communication, which included listening, providing information, and supporting the residents’ next-of-kin. One of the participants expressed this as follows:

When I observe that the resident’s health worsens, I inform the next-of-kin and invite the spouse or the children to a meeting together with the responsible doctor and I, and we inform the next-of-kin what they might expect. The end-of-life care is not only about the resident and their last days, but also is to care for their next-of-kin to meet their needs and to overcome guilt feelings, anger or sadness.… (PI1).

Another way to care for patients was to deliberately increase opportunities to exercise autonomy during the caring process. For instance, the focus group participants discussed issues around advanced life support during the resident’s last days of life. Being prepared and having knowledge were the preconditions that gave them the authority to identify and make decisions about residents’ needs in here-and-now moments, hence exercising their autonomy. Some participants shared their experiences with controversies between next-of-kins’ and nurses’ assessments of what is the best care for the residents during their last days of life. Therefore, the importance of taking the initiative to discuss and clarify the resident’s needs and preferences was emphasised during the focus group interview, as shown in the following quote:

Some next-of-kins express wishes for advance life support and hospitalisation for their loved ones… and sometimes, to meet their needs, we try this, but the resident is suffering. The resident comes back to us after one or two days… To avoid this, clear guidelines, and a dialogue between the resident, their next-of-kin and us at the very beginning [when the resident enters the nursing home] is important… I think that minimalising the occurrence of difficult or conflictual situations and relieving the sufferance is care for both resident and their next-of-kin (P8FG).

Care giving—knowing what, why, how and when

During the interviews, the participants also discussed the caregiving process and provided concrete examples of what their caregiving encompassed. Spending extra time with the resident, choosing to be in the room and holding their hand to maintain physical contact was perceived as an autonomous caring act and a deliberate choice. One participant described this as follows:

For me, it is important that the dying person feels or hears that I am here with him or her… how he or she feels in these moments matters to me. I do it because I want to do it.… (PI5).

Other participants said that being autonomous when they actually provided caregiving to residents helped them make continuous assessments based on knowledge about what , how , how much , when and why to care. Knowledge and skills were decisive factors in providing competent care and making autonomous decisions during the caregiving phase; hence, competence was perceived as a moral dimension of caregiving. One of the participants said the following:

Caregiving at end-of-life is not only about giving morphine according to the doctor’s prescription… it involves all the judgements you have to make, all the skills you have… from preventing the occurrence of bedsores to knowing when to stop feeding but preventing thirst… think about all this knowledge and experience you must have to be able to make autonomous bedside judgements about when , why and so on.… (PI2).

Care giving at the end-of-life was described as all the necessary activities a nurse does to provide comfort and compassionate care to a dying resident. Among these activities, providing fundamental care and keeping residents comfortable and free of pain were seen as parts of the caregiving process. Moreover, adequate pain relief and symptom management were described as the moral dimension of care giving at this stage of end-of-life care, as one of the participants from the focus group interview said:

You cannot be passive when you see that the resident is suffering. I cannot go home and think that I should have done one or the other. It is against the nurses’ code of ethics and my personal moral and ethical principles. You have to act… I have to do what is needed… first thing first… pain relief and then personal hygiene! (P9FG)

Some of the participants mentioned some challenges they encountered during the care giving process. They said that care giving implies also standing in demanding situations. The lack of healthcare personnel with necessary knowledge or formal palliative care education or handling ethical dilemmas was seen as demanding situations that influenced the provision of care giving. Most of the participants felt that they were alone during the decision-making processes, which increased their awareness of their professional autonomy:

Sometimes, during weekends or evenings, I am the only nurse among the healthcare staff, and I have an overall responsibility for all nursing home residents. I have to prioritise who gets my attention and who needs me the most. Things can happen, regardless of whether it is Friday evening or weekend. I have to make a decision and do what is needed: to be with the dying resident and to support his or her next-of-kin in that moment. (PI5)

Care receiving—assessing caregiving

Several participants stated that, during the care-giving process, it was important to assess how the resident receive the care provided at the end-of-life stage. This was possible by monitoring the resident’s state of being but to also assess the outcomes of their care giving activities. They also reflected on their assessments and how they subsequently dealt with those assessments.

All the participants were confident in their knowledge and with their care giving at the end-of-life stage. They were aware that their care activities had consequences for the residents’ physiological and psychosocial needs. The assessment of the resident’s state of being was made by nurses listening, observing and interpreting resident’s response to care giving as signs of comfort or discomfort. One of the participants explained this as follows:

When providing personal care, if the resident presents any signs that can be interpreted as discomfort, I think that priority number one is me not causing more pain or suffering. However, I also understand that this person needs more pain killers, so I have to make sure that this person receives adequate medicine. (PI5)

Some participants also discussed the importance of assessing their care giving activities. They mentioned the importance of their assessments of the benefits of all care giving against the burden of all interventions and treatments. Their professional autonomy allowed them to make decisions about how to eschew care giving that was inappropriately and burdensome and choose the best comforting care for the resident. The participants stated that knowledge and experience were important in making such decisions, and their professional autonomy facilitated making choices of the best and less burdensome care giving. One of the participants said the following:

We have to assess whether the care giving provided meets the resident’s needs or not, whether the care comforts or perceives it as a burden and how the resident responds to this provision of care. (PI4)

During the interviews, some of the participants revealed a feeling of guilt when assessing that care giving altered the resident’s state of being, thus leading to new needs for care. They also discussed that the moral obligation and intention to relieve the suffering of the resident should override the foreseen but unintended harmful effects of care giving, including medication or other care interventions. One of the participants shared her experience as follows:

I still remember the attitude some of us had for a while ago… too much or too often morphine depresses the respiration and leads to death… I was struggling with feelings of guilt and even moral distress when I observed residents were still suffering because the medication they received had little or maybe no effect. I called the doctor and explained the situation… usually, the experienced doctors listen to us… and he [the doctor] prescribed more morphine.… (PI3).

Documentation of the response to care giving was also an issue discussed during the interviews. Some participants emphasised the importance of keeping detailed reports for a proper assessment of the care giving and medication and its outcomes. All reports were digitally written. Informal discussions between nurses and next-of-kin were also documented, especially when next-of-kin evaluated the care their loved ones received. The participants indicated that the more written information there was, the better. One participant acknowledged the following:

There is no such thing as ‘too much information’… being open about the morphine’s side effects and what to expect in the next hours or days is important for them [next-of-kin]. It helps them understand that end-of-life care is a process, not a quick fix procedure. (PI5)

Caring with—It is a teamwork process

During the interviews, most of the participants reflected upon the end-of-life caring process and its occurrence within the context of care in nursing home. The participants discussed that end-of-life care is not only about the responsibilities nurses have towards residents and their next-of-kin, but also the responsibilities of others who may influence the caring process. They perceived the caring process as an interplay between residents, next-of-kin, and themselves, along with how they relate to each other, which influences the caring process. However, as several participants asserted, this process did not occur in a vacuum: it occurred within an organisational context, which then influenced the caring process from the very beginning. One participant emphasised the importance of stable healthcare personnel within a caring organisation:

High staff turnover does not facilitate good end-of-life caregiving. Both residents and their next-of-kin need continuity and predictability in caring for and among healthcare personnel. They need somebody they know and trust… being exposed to new people every day increases their stress levels. (PI1)

Other participants discussed the importance of the leadership style and how the leader’s support influenced the culture of end-of-life care at the ward. The participants revealed that, within a caring context where their natural potential was enhanced through an enabling leadership style, they felt that they could provide competent and compassionate end-of-life care. One of the participants from the focus group stated that a positive leadership style supports nurses’ professional autonomy, thus helping them control the caring process, to have independence and to increase their ability to make clinical decisions and competent judgements regarding resident’s end-of-life care. One participant shared her experience as follows:

My leader gives me the freedom to make decisions when it comes to deciding what is best for the resident… She [the leader] enables me to be autonomous during the caring process, and this makes me aware of what and how to care.… (PI2).

The participants from the focus group interview also discussed how the nursing home’s caring culture influences care practice. They perceived the nursing home’s caring culture as positive, enabling good end-of-life care but also defective and an obstacle to care. They emphasised the importance of providing dignifying end-of-life care for residents. During the focus group interview, two of the participants engaged in a dialogue:

End-of-life care is providing care to the most vulnerable people, and it should be dignified… To do so, I have to provide care in a ‘caring room’ filled with dignity. (P7FG) Although next-of-kin and I have different perspectives of what good end-of-life care might be, we care together, we are a caring team which ensures in our own way that the resident receives competent care.… Yes, you [P7] mentioned this ‘caring room’… maybe we should open the door more often into this room and invite next-of-kin. (P6FG)

The aim of the present study was to explore nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents. In the following, we discuss these perceptions in relation to Tronto’s [ 32 , 35 ] ethics of care framework and other supporting literature. To identify the moral dimension of these perceptions, we have related them to the moral qualities corresponding to each phase of the care process, as described by Tronto [ 33 , 35 ].

In the first phase of the care process—caring about—the participants discussed the importance of being attentive to which type of care needs to be provided, which is the moral quality of the first phase of care. Similar to findings from another study [ 49 ], findings from the present study revealed that some participants perceived autonomous practice as carrying out actions based on their decisions. Caring about entails detecting the resident’s needs, hence obliging nurses to ‘do something’ [ 50 ]. This particular skill was seen as an autonomous caring activity, that is, the nurses’ deliberate choice of putting on hold their self-interest and/or agenda and ‘a capacity genuinely to understand the perspective of the other in need’ [ 35 ] (p.34) , here nursing home resident.

In Tronto’s view [ 33 ], nurses’ attentiveness contributes to building up a caring relationship with a patient. The findings from the current study reveal that nurses perceived the provision of competent and compassionate end-of-life care as a result of their clinical gaze developed through certain activities, attitudes and knowledge of the patient, and through mutual relationships between the residents, next-of-kin and them. These results are supported by findings from previous studies that emphasise the importance of the nurse’s past experiences with the resident [ 51 ] and the significance of developing a good relationship with the resident and their next-of-kin [ 8 , 23 , 52 , 53 , 54 ] to provide adequate care. Moreover, similar to findings from other studies [ 55 , 56 ], the present study reveal that, to respond to the resident’s end-of-life care needs, nurses must bring not only their professional knowledge, clinical experience and ability to work autonomously but even ethical sensitivity. These findings enforce Gastman’s [ 50 ] view on caring, in which caring should respond to the patient’s care needs. This involves nurses having empathy, capacity of judgement and the ability to see what is required in a specific situation (here, end-of-life care), which, according to Gastmans [ 50 ], is inherent in the moral dimension of nursing practice.

The second phase of care—caring for—refers to nurses taking on the burden of meeting the needs identified in the first phase, that is, caring about. There was no ambiguity, and the participants had no doubts regarding who had the responsibility for the provision of end-of-life care to nursing home residents. The nurses’ responsibility was seen as a moral dimension of care. In line with Pursio et al.’s study [ 30 ], the present findings indicate that the freedom to make patient care decisions and work independently has a positive impact on the moral dimension of end-of-life care for nursing home residents. However, nurses’ work was not only about meeting residents’ needs, but also to create a safe milieu, a communicative space together with each other and with the resident’s next-of-kin, thus sharing power and control over the care process. Similar findings are displayed in an integrative literature review [ 53 ], demonstrating that a positive culture of collaborative and reciprocal relationships, a willingness to engage and become engaged and nurses communicating with intent to share and support rather than inform all lead to facilitating decision-making in nursing homes. According to Tronto [ 35 ], to facilitate end-of-life decision-making, nurses must take the initiative to allocate responsibilities; otherwise, the nurses withdraw themselves from their responsibility. By exercising their professional autonomy to assign responsibilities, nurses strive to mitigate the power imbalance among residents, their next-of-kin, and themselves, thereby preventing the occurrence of potential power struggles in their relationships [ 34 ]. This proactive approach helps prevent the emergence of end-of-life care dilemmas that could undermine the moral dimension of end-of-life care.

The third phase of care—care giving—requires, according to Tronto [ 35 ], the moral quality of nurses’ competence, meaning nurses directly engaging with care. The findings revealed that the nurses provided end-of-life care, and to do so, they needed to have competence, which implies the nurses having the knowledge, skills and values necessary to know what, why, how and when to provide end-of-life adequately. In addition, good end-of-life care requires the competence to individualise care—to provide competent care based on the resident’s physical, psychological, cultural and spiritual needs [ 57 ] while considering the resident’s context of care. Nurses’ competence is crucial for their autonomy; however, to effectively utilize their competence, nurses must be capable of assessing care needs and responding promptly [ 30 ]. Otherwise, delays in assessing residents’ care needs could undermine the moral dimension of end-of-life care. To provide individualised competent care, it is necessary that nurses make continuous assessments. As the findings reveal, the nurses were concerned with providing competent care, that is, adequate pain management. If the care provided was incompetent and led to more pain for the resident, the nurses perceived psychological distress—a state of being that resulted in response to a variety of moral events—leading to the nurses feeling anger, frustration, guilt, powerlessness and stress [ 58 ]. According to Tronto [ 34 ] (p.17) , ‘incompetent care is not only a technical problem, but a moral one’; however, as the findings reveal, the provision of competent care also depends on the nurses’ ability to prioritise decision-making when standing alone. Although nurses’ professional autonomy enabled them to make decisions and choose the right what , how , how much , when , and why , the lack of adequately educated healthcare personnel make the decision-making process a technical problem, which could weaken the moral dimension of end-of -life care.

The fourth phase—care receiving—involves the moral quality responsiveness. This means nurses being responsive to the reaction of the nursing home residents to end-of-life care process. As the findings have revealed, nursing home residents are vulnerable to nurses’ act of care or lack of care. According to Gastmans [ 59 ], care is a reciprocal practice that occurs within the framework of a relationship between the care provider (nurse) and care receiver (resident). The reciprocity consists of nurses assessing that the care provided actually meets the resident’s needs for pain management and other physiological and spiritual needs. The nurses had to make autonomous end-of-life care decisions to meet the resident’s needs. This involved the nurse’s attention to care giving to not be perceived as power abuse, which could have negative consequences for the moral dimension of end-of-life care provision.

According to Tronto [ 33 ], vulnerability may lead to unequal relationships where power abuse may occur. Nursing home residents are in a vulnerable position because they rely on nurses’ competence and ability to alleviate suffering and assess and reassess the residents’ responsiveness to pain management. To avoid an unequal relationship between resident and nurse, nurses must assess whether the care provided is competent or incompetent. Besides assessing and documenting the care provided and its outcomes, informal discussions between the resident’s next-of-kin and nurses were also assessed as important for next-of-kin perceiving a balanced power and equal position within the relationship. However, because each end-of-life act of care may alter the resident’s state of being, responsiveness requires more attentiveness [ 34 ]. Nurses must therefore meet the resident’s new needs for care with compassion and a commitment to maintaining the highest quality of life throughout the evolving stages of the resident’s end-of-life journey.

The final phase of care—caring with—requires that solidarity and trust are the foundation of all care giving to meet caring needs [ 35 ]. The moral quality of this caring phase is solidarity. The findings from the present study suggest that the nurses felt solidarity with both the residents and their leaders. The nurses felt that they were given the support and freedom to act autonomously when making decisions regarding end-of-life care, but similar to findings from a previous study [ 22 ], they also recognised the impact that organisational factors, such as leadership and care culture, may have on the justice and equality of the care provided when they prioritise care to whom needed it the most. Similar to findings from another study [ 49 ], participants in the present study described autonomy as the ability to make independent decisions and prioritise care for those who needed it most. However, according to Tronto [ 35 ], all nurses have a responsibility to help determine how care activities and responsibilities should be allocated. Residents, their next-of-kin and other healthcare personnel may have different views on how they may perceive appropriate, compassionate and dignified end-of-life care [ 20 , 21 ].Therefore, it is important to have transparency in nurse–resident–next-of-kin relations if the element of power within the relationship should be replaced by trust. Otherwise, the nurses’ autonomy may negatively influence the moral dimension of end-of-life care provided to nursing home residents. By opening the door of the “caring room” and inviting next-of-kin to participate in the care process, nurses may contribute to a greater reflectiveness around what may constitute ‘good’ end-of-life care.

Strengths and limitations

One of the strengths of the study is the use of Joan Tronto’s theory of the ethics of care [ 32 , 34 , 35 ] and its five phases and elements of care to discuss the study’s findings. This allows a deeper understanding of how nurses’ professional autonomy influences the moral dimension of end-of-life care provided to nursing home residents. Another strength lies in the utilisation of two distinct methods of data collection: individual and focus group interviews. These approaches provided diverse datasets that shed light on various aspects of how nurses’ professional autonomy impacts the moral dimension of end-of-life care. Furthermore, the inclusion of participants with varying work experiences from four nursing homes enhances the richness and depth of the data generated from the interviews, further strengthening the quality of the study. Member checking ensures that the researcher’s interpretations accurately reflect the participants’ experiences and perspectives, thereby enhancing the validity of the study. This practice can be considered one of the methodological strengths of the study.

The current study has also some limitations that need to be considered. First, a limitation may be related to the size of the participant sample. The sample consisted of only nine nurses, a number that may be seen as a limitation in data collection. To challenge this limitation, the researchers posed follow-up questions during the interviews, thus offering the participants the opportunity to provide rich descriptions of their experiences with end-of-life care. Even though the sample consisted of only nine nurses, these participants reflected on and described their everyday work experiences. The participants’ rich descriptions were evaluated as possessing sufficient information power [ 41 ], thereby enhancing the overall quality of dialogues during interviews– a notable strength.

Second, the findings are limited to these nine participants and their personal work experiences in four different Norwegian nursing homes. This means that the sample is small and context dependent, which may limit the transferability and generalisability of the findings.

A third limitation pertains to the potential influence of the chosen theoretical framework on researchers’ preunderstanding during data analysis. To avoid bias, the theoretical framework was introduced at the end of the data analyses and after the coding process was conducted. The theoretical framework contributed to situating the knowledge from the empirical data into theoretical knowledge and vice versa. However, to be certain about interpretations and knowing that the qualitative nature of the study cannot completely exclude the impact of the preunderstanding on the analysis of the data, both researchers were aware of their theoretical preunderstanding and tried not to make conclusions beforehand.

The ethics of care framework provides opportunities for nurses to analyse their own caring activities during the provision of end-of-life care to nursing home residents. The exploration of the moral dimension of the provision of end-of-life care, utilising Tronto’s theory, revealed that moral qualities, such as attentiveness, responsibility, competence, responsiveness, and solidarity are influenced to a certain extent by nurses’ autonomy. What is crucial for the provision of competent end-of-life care is the nurses’ awareness of acting properly in accordance with the moral qualities to each of the phases of caring. Therefore, to provide competent end-of-life care nurses must be attentive to residents’ care needs, take on the responsibility for the care provided to ensure that residents’ needs are met, provide competent care based on knowledge, skills and values and assess how residents respond to the care provided. In other words, this is the basic nursing process in action, and this problem-solving approach is needed for the provision of competent end-of-life care.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Oslo Metropolitan University.

Abbreviations

Participant in interview [number of the individual interview

Participant [number] in Focus Group interview

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Acknowledgements

We would like to express gratitude to the nurses who participated in this study, thereby contributing to the data collection. Additionally, we extend our thanks to the Oslo Metropolitan University Library for granting approval and for their support in covering the publication fee of this article.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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D.L. contributed to the study conception, data collection, and analysis, and wrote the main manuscript text. R.G. was involved in data collection, analysis, reflection, and manuscript writing. D.L. was responsible for administrative work related to journal submission and was also involved in reviewing and editing the manuscript. R.G. and D.L. have read and approved the manuscript before submission.

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The Norwegian Agency for Shared Services in Education and Research approved the study protocol (Sikt/Ref. number 360657) and concluded that the study was not subject to the Norwegian Health Research Act (LOV-2008-06-20-44; https://lovdata.no/dokument/NL/lov/2008-06-20-44 ). An English version of the Norwegian Health Research Act can be found at: https://www.uib.no/en/med/81598/norwegian-health-research-act . This study does not aim to get insight into participants’ health status, sexuality, ethnicity, and political affiliation (sensitive information), therefore, no additional approval from a local ethics committee or institutional review board (IRB) was necessary to be obtained to conduct the study. This study was performed according to principles outlined in the Declaration of Helsinki, and in accordance with Oslo Metropolitan University’s guidelines and regulations. Data were kept confidential and used only for this research purpose. The researchers provided verbal and written information about the study. Informed consent was obtained from all participants prior data collection.

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Gilbert, R., Lillekroken, D. Nurses’ perceptions of how their professional autonomy influences the moral dimension of end-of-life care to nursing home residents– a qualitative study. BMC Nurs 23 , 216 (2024). https://doi.org/10.1186/s12912-024-01865-5

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