Issues and Trends in Nursing: Essential Knowledge for Today and Tomorrow
Student Elements

Reflective Case Studies

Please read each question below and type your response into each corresponding box. When you are finished, fill out your name, e-mail address, and instructor's e-mail at the bottom of this form, and click submit to send a copy to your instructor.

A Historical Event to Demonstrate Importance of the Art and Science of Nursing, Nursing Roles, and Leadership. The following case is a true story. After reading the case, respond to the questions.

In the 1960s, something significant began to happen in hospital care and, ultimately, in the nursing profession. But first, let's go back to the 1950s for some background information.There was increasing interest in coronary care during this time, particularly for acute myocardial infarctions (AMIs). It is important to remember that changes in health care are certainly influenced by changes in science and technology, but incidents and situations within the country as a whole also drive change and policy decisions. This situation was no exception. Presidents Eisenhower and Johnson both had AMIs, which received a lot of press coverage. The mortality rate from AMIs was high. There were also significant new advances in care monitoring and interventions: cardiac catherization, cardiac pacemakers, continuous monitoring of cardiac electrical activity, portable cardiac defibrillator, and external pacemakers. This really was an incredible list to come onto the scene at the same time.

Now, what was happening with nursing in the 1950s regarding the care of cardiac patients? Even with advances, nurses were providing traditional care, and the boundaries between physicians and nurses were very clear.

Examined the patientMade the patient comfortable
Took the EKGTook care of the patient's belongings
Drew blood for lab work Answered the family's questions
Diagnosed cardiac arrhythmiasTook vital signs (blood pressure, pulse, respirations)
Determined interventionsMade observations and documented them

In the 1960s, change began to happen. Bethany Hospital in Kansas City had a physician, Dr. Hughes Day, who had an interest in cardiac care. The hospital redesigned its units, moving away from open wards to private and semiprivate rooms. This was nice for the patients, but it made it difficult for nurses to observe patients. (This is a good example of how environment and space impact care.) Day established a Code Blue to provide response to patients having critical cardiac episodes. This was a great idea but often came too late for many patients who were not observed early enough. He also instituted monitoring of patients with cardiac problems who were unstable. Another good idea, but what would happen if there was a problem? Who would intervene, and how? Day would often be called, even at home at night, but how could he get to the hospital in time in such a critical situation? Nurses had no training or experience with the monitoring equipment or in recognizing arrhythmias, or knowledge about what to do if there were problems. Day (1972) was beginning to see that his ideas needed revision.

At the same time that Day was exploring cardiac care, Dr. L. Meltzer was involved in similar activity at the Presbyterian Hospital in Philadelphia. Each did not know of the work that the other was doing. Meltzer went about the problem a little differently. He knew that a separate unit was needed for cardiac patients, but he was less sure about how to design it and how it would function. Meltzer approached the Division of Nursing, U.S. Public Health Services, for a grant to study the problem. He wanted to establish a two-bed cardiac care unit (CCU). His research question was, Will nurse monitoring and intervention reduce the high incidence of arrhythmic deaths from AMIs? At this time, and good for nursing, Faye Abdella, PhD, RN, was leading the Division of Nursing. She really liked the study proposal but felt that there was something important missing. To receive the grant, Meltzer needed to have a nurse lead the project. Meltzer proceeded to look for that nurse. He turned to the University of Pennsylvania and asked the dean of nursing for a recommendation. Rose Pinneo, MSN, RN, a nurse who had just completed her master's and had experience in cardiac care, was selected. Meltzer and Pinneo became a team. Pinneo liked research and wanted to do this kind of work By chance, she had her opportunity. What she did not know was that this study and its results would have a major impact on the nursing profession.

Dr. Zoll, who worked with Meltzer, recognized the major issue: Nurses had no training in what would be required of them in the CCU. This represented a major shift in what nurses usually did. If this was not changed, no study could be conducted based on the research question that they had proposed. Notably, Meltzer proposed a new role for nurses in CCU:

  • The nurse has specific skills in monitoring patients using the new equipment.

  • RNs would provide all the care. Up until this time, the typical care organization was a team of licensed practical nurses and aides, who provided most of the direct care, led by an RN (team nursing).This had to change in the CCU.

  • RNs would interpret heart rhythms using continuous-monitoring EKG data.

  • RNs would initiate emergency interventions when needed.

  • The RN, not the MD, is central to CCU care 24-7.

There were questions as to whether RNs could be trained for this new role, but Meltzer had no doubt that they could be.

In 1963, Rose Pinneo entered the picture. Based on Meltzer's plan and the new role, she needed to find the nurses for the units. She wanted nurses who were ready for a challenge and who were willing to learn the new knowledge and skills needed and to collect data. Collecting data would be time consuming, plus the nurses had to provide care in a very new role. The first step after finding the nurses was training. This too was unique. It was interdisciplinary, and it took place in the clinical setting, the CCU.Clinical conferences were held to discuss patients and their care once the unit opened.

The nurses found that they were providing care for highly complex problems. They were assessing and diagnosing, intervening, and having to help patients with their psychological responses to having had an AMI. Clearly, knowledge and caring were important, but added to this was curing. With the interventions that nurses initiated, they were saving lives. Standing orders telling nurses what to do in certain situations based on data they collected were developed by Meltzer and used. House staff, physicians in training, began to turn to the nurses to learn because the CCU nurses had experience with these patients. Meltzer called his approach the scientific team approach.

1:  Based on this case, discuss the implications of the art and science of nursing.

2:  Who led this initiative? Why is this significant?

3:  Compare and contrast the changes in nursing roles before the Melzer and Day studies. What was the role supported by their work?

4:  What about this case is unique and unexpected?

5:  What does this case tell you about the value of research?

When nursing began in the home, it was considered the safest place to recover from an illness. With all the advances and discoveries made by early nurse leaders like Florence Nightingale, Mary Breckenridge and Lillian Wald, to name a few, do you think they would agree with how nursing is returning to the home?

6:  Patients are being discharged from the hospital after 24-72 hours of care and are dying with respect in the home. State reasons based on the descriptions provided for the nurses who most influenced the profession in the 18th and 19th centuries.

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