Nursings Social Policy Statement: An Overview
“Nursing is the pivotal health care profession, highly valued for its specialized knowledge, skill, and caring in improving the health status of the public and ensuring safe, effective, quality care.”
This revision of Nursing’s Social Policy Statement is the culmination of an extensive review process that also included a long public comment period. It builds on previous editions, especially the original 1980 document. The work describes the essence of the profession by discussing nursing as a profession that is both valued within a society and uniquely accountable to that society. The definition of nursing follows and describes contemporary nursing practice. A more detailed discussion of practice is presented in the sections about the scope and standards of practice and professional performance. A brief commentary about regulation provides an overview of professional, legal, and self-regulation expectations. This foundational ANA publication remains a key resource for nurses both to conceptualize the framework of nursing practice and to provide direction to nursing educators, administrators, and researchers. This publication also can inform other health professionals, legislators and other regulators, those who work in funding bodies, and members of the general public.
Social Context of Nursing
“Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.”
Nursing, like other professions, is an essential part of the society out of which it grew and within which it continues to evolve. Nursing is responsible to society in the sense that nursing’s professional interest must be perceived as serving the interests of society. The mutually beneficial relationship between society and the nursing profession has been expressed as follows:
Professions acquire recognition and relevance primarily in terms of needs, conditions, and traditions of particular societies and their members. It is societies (and often vested interests within them) that determine, in accord with their different technological and economic levels of development and their socioeconomic, political, and cultural conditions and values, what professional skills and knowledge they most need and desire. By various financial means, institutions will then emerge to train [educate] interested individuals to supply those needs.
Logically, then, the professions open to individuals of any particular society are the property not of the individual, but of the society. What
individuals acquire through training [education] is professional knowledge and skill, not a profession or even part ownership of one. (Page, 1975, p. 7)
The Social Concerns in Health Care and Nursing
Health care continues to be a major focus of attention in the United States and worldwide. Many other societal concerns garner extensive attention and subsequent action by the nursing profession and its nurse constituency. Nursing has an active and enduring leadership role in public and political determinations about the following six key areas of health care:
Organization, delivery, and financing of quality health care
Quality health care is a human right for all (ANA, 2008b). To improve the quality of care, healthcare professionals must address these complex issues: increasing costs of care; health disparities; and the lack of safe, accessible, and available healthcare services and resources.
Provision for the public’s health
Increasing responsibility for basic self-help measures by the individual, family, group, community, or population complements the use of health promotion, disease prevention, and environmental measures.
Expansion of nursing and healthcare knowledge and appropriate application of technology
Incorporation of research and evidence into practice helps inform the selection, implementation, and evaluation processes associated with the generation and application of knowledge and technology to healthcare outcomes.
Expansion of healthcare resources and health policy
Expanded facilities and workforce capacity for personal care and community health services are needed to support and enhance the capacity for self-help and self-care of individuals, families, groups, communities, and populations.
Definitive planning for health policy and regulation
Collaborative planning is responsive to consumer needs and provides for best resource use in the provision of health care for all.
Duties under extreme conditions
Health professionals will weigh their duty to provide care with obligations to their own health and that of their families during disasters, pandemics, and other extreme emergencies.
Of increasing importance, healthcare regulatory bodies set institutional standards for mandated quality of care, and other healthcare entities provide guidelines and protocols to attain quality care and better outcomes. The goals to provide quality while addressing the costs and quantity of available healthcare services will continue to be social and political priorities for nursing action.
The Authority for Nursing Practice for Nurses
The authority for nursing, as for other professions, is based on social responsibility, which in turn derives from a complex social base and a social contract.
There is a social contract between society and the profession. Under its terms, society grants the professions authority over functions vital to itself and permits them considerable autonomy in the conduct of their own affairs. In return, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality and performance is at the heart of this relationship. It is the authentic hallmark of the mature profession. (Donabedian, 1976)
Nursing’s social contract reflects the profession’s long-standing core values and ethics, which provide grounding for health care in society. It is easy to overlook this social contract underlying the nursing profession when faced with certain facets of contemporary society, including depersonalization, apathy, disconnectedness, and growing globalization. But upon closer examination, we see that society validates the existence of the profession through licensure, public affirmation, and legal and legislative parameters. Nursing’s response is to provide care to all who are in need, regardless of their cultural, social, or economic standing.
The nursing profession fulfills society’s need for qualified and appropriately prepared individuals who embrace, and act according to, a strong code of ethics, especially when entrusted with the health care of individuals, families, groups, communities, and populations. The public ranks nurses among the top-few most trusted professionals. In turn, the nursing profession’s trusted position in society imposes a responsibility to provide the very best health
care. The provision of such health care relies on well-educated and clinically astute nurses and a professional association, comprising these same nurses, that establishes a code of ethics, standards of care and practice, educational and practice requirements, and policies that govern the profession.
The American Nurses Association (ANA) is the professional organization that performs an essential function in articulating, maintaining, and strengthening the social contract that exists between nursing and society, upon which the authority to practice nursing is based. That social contract is evident in ANA’s most enduring and influential work, which is derived from the collective expertise of its constituent member associations, individual members, and affiliate member organizations. Such work includes:
Developing and maintaining nursing’s code of ethics;
Developing and maintaining the scope and standards of nursing practice;
Supporting the development of nursing theory and research to explain observations and guide nursing practice;
Establishing the educational requirements of professional practice;
Defining professional role competence; and
Developing programs and resources to establish and articulate nursing’s accountability to society, including practice policy work and governmental advocacy.
The Elements of Nursing’s Social Contract
The following statements undergird professional nursing’s social contract with society:
Humans manifest an essential unity of mind, body, and spirit.
Human experience is contextually and culturally defined.
Health and illness are human experiences. The presence of illness does not preclude health, nor does optimal health preclude illness.
The relationship between the nurse and patient occurs within the context of the values and beliefs of the patient and nurse.
Public policy and the healthcare delivery system influence the health and well-being of society and professional nursing.
Individual responsibility and interprofessional involvement are essential.
These values and assumptions apply whether the recipient of professional nursing care is an individual, family, group, community, or population.
Professional Collaboration in Health Care
The nursing profession is particularly focused on establishing effective working relationships and collaborative efforts essential to accomplish its health-oriented mission. Multiple factors combine to intensify the importance of direct human interactions, communication, and professional collaboration: the complexity, size, and culture of the healthcare system and its transitional and dynamic state; increasing public involvement in health policy; and a national focus on health.
Collaboration means true partnership, valuing expertise, power, and respect on all sides and recognizing and accepting separate and combined spheres of activity and responsibility. Collaboration includes mutual safeguarding of the legitimate interests of each party and a commonality of goals that is recognized by all parties. The parties base their relationship upon trust and the recognition that each one’s contribution is richer and more truly real because of the strength and uniqueness of the others.
Successful collaboration requires that nursing and its members respond to diversity by recognizing, assessing, and adapting the nature of working relationships with individuals, populations, and other health professionals and health workers. These efforts also extend to relationships within nursing and between nursing and representatives of the public in all environments where nursing practice may occur.
Definition of Nursing
Definitions of nursing have evolved to reflect the essential features of professional nursing:
Provision of a caring relationship that facilitates health and healing
Attention to the range of human experiences and responses to health and illness within the physical and social environments
Integration of assessment data with knowledge gained from an appreciation of the patient or the group
Application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking
Advancement of professional nursing knowledge through scholarly inquiry
Influence on social and public policy to promote social justice
Assurance of safe, quality, and evidence-based practice
In her Notes on Nursing: What It Is and What It Is Not, published in 1859, Florence Nightingale defined nursing as having “charge of the personal health of somebody…, and what nursing has to do … is to put the patient in the best condition for nature to act upon him.”
A century later, Virginia Henderson (1961) defined the purpose of nursing as “to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.”
In the original Nursing: A Social Policy Statement (ANA, 1980), nursing was defined as “the diagnosis and treatment of human responses to actual or potential health problems.”
In 2001, ANA’s Code of Ethics With Interpretive Statements stated that “nursing encompassed the prevention of illness, the alleviation of suffering, and the protection, promotion and restoration of health in the care of individuals, families, groups, and communities.”
The definition for nursing remains unchanged from the 2003 edition of Nursing’s Social Policy Statement:
Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.
This definition encompasses four essential characteristics of nursing: human responses or phenomena, theory application, nursing actions or interventions, and outcomes.
These are the responses of individuals to actual or potential health problems, and which are the phenomena of concern to nurses. Human responses include any observable need, concern, condition, event, or fact of interest to nurses that may be the target of evidence-based nursing practice.
In nursing, theory is a set of interrelated concepts, definitions, or propositions used to systematically describe, explain, predict, or control human responses or phenomena of interest to nurses. Understanding theories of nursing and other disciplines precedes, and serves as a basis for, theory application through evidence-based nursing actions.
The aims of nursing actions (also nursing interventions) are to protect, promote, and optimize health; to prevent illness and injury; to alleviate suffering; and to advocate for individuals, families, communities, and populations. Nursing actions are theoretically derived, evidence-based, and require welldeveloped intellectual competencies.
The purpose of nursing actions is to produce beneficial outcomes in relation to identified human responses. Evaluation of outcomes of nursing actions determines whether the actions have been effective. Findings from nursing research provide rigorous scientific evidence of beneficial outcomes of specific nursing actions.
Figure 1 depicts the intertwined relationships of human responses, theory application, nursing actions, and outcomes.
Knowledge Base for Nursing Practice
Nursing is a profession and is both a science and an art. The knowledge base for professional nursing practice includes nursing science, philosophy, and ethics; biology and psychology; and the social, physical, economic, organizational, and technological sciences. To refine and expand nursing’s knowledge base, nurses use theories that fit with professional nursing’s values of health and health care and that are relevant to professional nursing practice. Nurses apply research findings and implement the best evidence into their practice based on applicability to the individual, family, group, community, population, or system of care. These efforts generate knowledge and advance nursing science.
Nurses are concerned with human experiences and responses across the life span. Nurses partner with individuals, families, communities, and populations to address issues such as the following:
Promotion of health and wellness
Promotion of safety and quality of care
Care, self-care processes, and care coordination
Physical, emotional, and spiritual comfort, discomfort, and pain
Adaptation to physiological and pathophysiological processes
Emotions related to the experience of birth, growth and development, health, illness, disease, and death
Meanings ascribed to health, illness, and other concepts
Linguistic and cultural sensitivity
Decision making and the ability to make choices
Relationships, role performance, and change processes within relationships
Social policies and their effects on health
Healthcare systems and their relationships to access, cost, and quality of health care
The environment and the prevention of disease and injury
Nurses use their theoretical and evidence-based knowledge of these human experiences and responses to collaborate with patients and others to assess, diagnose, plan, implement, evaluate care, and identify outcomes. Nursing interventions aim to produce beneficial effects, contribute to quality outcomes, and—above all—do no harm. Nurses use the process that is evidence-based practice as a foundation of quality patient care to evaluate the effectiveness of care in relationship to identified outcomes.
Scope of Nursing Practice
Professional nursing has a single scope of practice that encompasses the range of activities from those of the beginning registered nurse through those of the most advanced level of nursing practice. The scope of practice statement (ANA, 2010) describes the who, what, where, when, why, and how of nursing practice. Although a single scope of professional nursing practice exists, the depth and breadth to which individual nurses engage in the total scope of professional nursing practice are dependent on their educational preparation and self-development, their experience, their role, the setting, and the nature of the populations they serve.
Further, all nurses are responsible for practicing in accordance with recognized standards of professional nursing practice and the recognized professional code of ethics. Note that the lower level and foundation of the pyramid in Figure 2 (see next page) includes the scope of professional practice, standards of practice, and the code of ethics.
Each nurse remains accountable for the quality of care within his or her scope of nursing practice. The level of application of standards varies with the education, experience, and skills of the individual nurse, who must rely on self-determination and self-regulation as the final level of professional accountability.
Professional nursing’s scope of practice is dynamic and continually evolving, characterized by a flexible boundary responsive to the changing needs of society and the expanding knowledge base of applicable theoretical and
scientific domains. This scope of practice thus overlaps those of other professions involved in health care, whose boundaries are also constantly evolving. Members of any profession collaborate in various ways, such as:
FIGURE 2. MODEL OF PROFESSIONAL NURSING PRACTICE
Sharing knowledge, techniques, and ideas about how to deliver and evaluate quality and outcomes in health care
Sharing some functions and a common focus on the same overall mission
Recognizing the expertise of others within and outside the profession, referring patients to other providers when appropriate
Nursing practice necessitates using such critical-thinking processes as the nursing process to apply the best available evidence to caregiving and promoting human functions and responses. Such caregiving includes, but is not limited to, initiating and maintaining comfort measures, establishing an environment conducive to well-being, providing health counseling, and teaching. Nurses not only independently establish plans of care but also carry out interventions prescribed by other authorized healthcare providers. Therefore, advocacy, communication, collaboration, and coordination are notable characteristics of nursing practice. Nurses base their practice on understanding the human condition across the life span and the relationship of the individual, family, group, community, or population within their own setting and environment.
Registered nurses and nurses with advanced graduate education and preparation provide and direct nursing care. All registered nurses are educated in the art and science of nursing, with the goal of helping individuals, families, groups, communities, and populations to promote, attain, maintain, and restore health or to experience dignified death. Nurses may also develop expertise in a particular specialty. The increasing complexity of care reinforces ANA’s consistent advocacy (since 1965) of the baccalaureate degree in nursing as the preferred educational requirement for entry into professional nursing practice.
Specialization in Nursing Practice
Specialization involves focusing on nursing practice in a specific area, identified from within the whole field of professional nursing. ANA and specialty nursing organizations delineate the components of professional nursing practice that are essential for any particular specialty. The following characteristics must be met for ANA recognition of a nursing specialty. A nursing specialty (ANA, 2008d):
Defines itself as nursing;
Adheres to the overall licensure requirements of the profession;
Subscribes to the overall purposes and functions of nursing;
Is clearly defined;
Can identify a need and demand for itself;
Has a well-derived knowledge base particular to the practice of the nursing specialty;
Is concerned with phenomena of the discipline of nursing;
Defines competencies for the area of specialty nursing practice;
Has existing mechanisms for supporting, reviewing, and disseminating research to support its knowledge base;
Has defined educational criteria for specialty preparation or graduate degree;
Has continuing education programs or continuing competence mechanisms for nurses in the specialty;
Is organized and represented by a national or international specialty association or branch of a parent organization;
Is practiced nationally or internationally; and
Includes a substantial number of registered nurses who devote most of their practice to the specialty.
Registered nurses may seek certification in a variety of specialized areas of nursing practice as a demonstration of competence (ANA, 2008c).
Advanced Nursing Practice
Advanced nursing practice builds on the competencies of the registered nurse and is characterized by the integration and application of a broad range of theoretical and evidence-based knowledge that occurs as part of graduate nursing education.
Advanced Practice Registered Nurses
Advanced practice registered nurses (APRNs) hold master’s or doctoral degrees in nursing, are certified in their designated specialty practice areas, and are recognized and approved to practice in their roles by state boards of nursing or other regulatory oversight bodies, often through special professional licensing processes.
APRNs are educationally prepared in one of the four APRN roles (certified nurse practitioners, certified registered nurse anesthetists, certified nurse-midwives, and clinical nurse specialists) and in at least one of six possible population foci: family/individual across the life span; adult/gerontology; neonatal;
pediatrics; women’s health/gender-related health; psychiatric/mental health). Education, certification, and licensure of these individuals should be congruent with role and population foci (APRN Consensus, 2008). APRN specialty practice may focus on specific populations beyond those identified or focus on healthcare needs (such as oncology, palliative care, substance abuse, nephrology) that meet criteria for specialization as identified in the APRN Consensus Model. (See Appendix A for the full text of the APRN Consensus Model.)
Additional Specialized Advanced Nursing Positions
The profession of nursing is also dependent on continued expansion of nursing knowledge, education of nurses, appropriate organization and administration of nursing services, and development and adoption of policies consistent with values and assumptions that underlie the scope of professional nursing practice. Registered nurses may practice in such advanced positions as nurse educator, nurse administrator, nurse researcher, nurse policy analyst, advanced public health nurse, and informatics nurse specialist. These advanced roles require specific additional knowledge and skills gained through graduate-level education, holding master’s or doctoral degrees.
Further details on the scope of professional nursing practice and the specifics that describe the who, what, where, when, why, and how of nursing practice for all registered nurses appear in the current version of Nursing: Scope and Standards of Practice (ANA, 2010).
Standards of Professional Nursing Practice
To guide professional practice, nursing has established standards of professional nursing practice, which are further categorized into standards of practice and standards of professional performance.
Definition and Function of Standards
Standards are authoritative statements by which the nursing profession describes the responsibilities for which its practitioners are accountable. Standards reflect the values and priorities of the profession and provide direction for professional nursing practice and a framework for the evaluation of this practice. They also define the nursing profession’s accountability to the public and the outcomes for which registered nurses are responsible (ANA, 2010).
Development of Standards
A professional nursing organization has a responsibility to its members and to the public it serves to develop standards of practice and standards of professional performance that may pertain to general or specialty practice. The American Nurses Association, as the professional organization for all registered nurses, has assumed the responsibility for developing generic standards that apply to the practice of all professional nurses. However, standards belong to the profession and thus require broad input into their development and
revision. The scope and standards of practice developed by ANA describe a competent level of nursing practice and professional performance common to all registered nurses (ANA, 2010).
Standards of Professional Nursing Practice
The Standards of Professional Nursing Practice are comprised of the Standards of Practice and the Standards of Professional Performance.
Standards of Practice
The Standards of Practice describe a competent level of nursing care, as demonstrated by the critical thinking model known as the nursing process, which includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. These standards encompass significant actions taken by registered nurses and form the foundation of the nurse’s decision making.
Standards of Professional Performance
The Standards of Professional Performance describe a competent level of behavior in the professional role, including activities related to quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, resource utilization, and leadership. Registered nurses are accountable for their professional actions to themselves, their patients, their peers, and ultimately to society.
The nursing process is usually conceptualized and presented as the integration of singular, concurrent actions of assessment, diagnosis, identification of outcomes, planning, implementation, and, finally, evaluation. Most often the nursing process is introduced to nursing students as a linear process with a feedback loop from evaluation to assessment, as reflected in Figure 3.
Figure 4 reflects how the nursing process in practice is not linear, but relies heavily on the bidirectional feedback loops from and to each component. The standards of practice are co-located near the steps of the nursing process to represent the directive nature of the standards as the professional nurse completes each component of the nursing process. Similarly, the standards of professional performance relate to how the professional nurse adheres to the standards of practice, completes the nursing process, and addresses other nursing practice issues and concerns.
FIGURE 3. THE NURSING PROCESS
FIGURE 4. THE NURSING PROCESS AND THE STANDARDS OF PROFESSIONAL NURSING PRACTICE
Application of Scope and Standards
Content within the current edition of Nursing: Scope and Standards of Practice should serve as the basis for the following:
Policies, procedures, and protocols
Position descriptions and performance appraisals
Educational programs and offerings
Development and evaluation of nursing service delivery systems and organizational structures, including the application of technologies
Specialty nursing scope and standards of practice
Quality improvement systems
Healthcare reimbursement and financing methodologies
Establishing the legal standard of care
Code of Ethics for Nurses
The current code of ethics for the profession, Code of Ethics for Nurses With Interpretive Statements (ANA, 2001) “functions as a general guide for the profession’s members and as a social contract with the public that it serves” (Fowler, 2008, p. xi). It is the profession’s expression of the values, duties, and commitments to that public. Its nine provisions give voice to professional nurses and delineate what the nurse owes not only to others but also to him- or herself. This includes, but is not limited to, personal and professional growth, preserving integrity, and safety (Fowler, 2008).
Although the Code of Ethics for Nurses is intended to be a living document for nurses, and health care is becoming more complex, the basic tenets found within this particular code of ethics remain unchanged. For example, Guide to the Code of Ethics for Nurses: Interpretation and Application (Fowler, 2008) provides interpretation and examples of the application of the nine ethical provisions.
Autonomy and Competent Practice
Autonomy is the capacity of a nurse to determine his or her own actions through independent choice within the full scope of nursing practice (Ballou, 1998). Competence is foundational to autonomy: the public has a right to expect nurses to demonstrate professional competence. The nursing profession and professional associations must shape and guide any practice, assuring nursing competence.
The key indicators of competent practice are identified with each standard of practice and professional performance. For a standard to be met, all the listed competencies must be met. An individual who demonstrates competence is performing successfully at an expected level. A competency is an expected level of performance that integrates knowledge, skills, abilities, and judgment. Standards should remain stable over time because they reflect the philosophical values of the profession. Competency statements, however, may be revised more frequently to incorporate advances in scientific knowledge and expectations for nursing practice.
Assurance of competence is the shared responsibility of the profession, individual nurses, professional organizations, credentialing and certification entities, regulatory agencies, employers, and other key stakeholders (ANA, 2008c).
Regulation of Professional Nursing
Figure 5 (see next page) depicts the roles and relationships associated with the regulation of nursing practice. The model recognizes the contributions of professional and specialty nursing organizations, educational institutions, credentialing and accrediting organizations, and regulatory agencies; explains the role of workplace policies and procedures; and confirms the individual nurse’s ultimate responsibility and accountability for defining nursing practice (Styles, Schumann, Bickford, & White, 2008).
The Scope of Nursing Practice, the Standards of Professional Nursing Practice, and the Code of Ethics for Nurses serve as the foundation for legislation and regulatory policies to assure protection of the public’s safety (Styles, Schumann, Bickford, & White, 2008).
Under the terms of a social contract between society and the profession, society grants authority over functions vital to the profession and permits considerable autonomy in the conduct of its own affairs. Professional nursing, like other professions, is accountable for ensuring that its members act in the public interest while providing the unique service that society has entrusted to them. The processes by which the profession does this include professional regulation, legal regulation, and self-regulation. The Scope of Nursing Practice, the Standards of Professional Nursing Practice, the Code of Ethics for Nurses, and the current social policy statement are components of professional regulation and serve as the foundation for legislation, regulatory policy making, and nursing practice that may be set in place to help assure protection of the public’s safety.
FIGURE 5. MODEL OF PROFESSIONAL NURSING PRACTICE REGULATION
Professional regulation is a profession’s oversight, monitoring, and control of its members based on principles, guidelines, and rules deemed important. Professional regulation of nursing practice begins with the professional definition of nursing and the delineation of the scope of professional nursing practice. Professional standards are derived from the scope of nursing practice.
The social contract for nursing has been made specific through the professional society’s work, derived from the collective expertise of the American Nurses Association, in collaboration with members of its constituent member associations and members of other nursing organizations. These responsibilities include the following:
Establishing and maintaining a professional code of ethics
Determining standards of practice
Fostering the development of nursing theory, derived from nursing research
Establishing nursing practice built on a base of best evidence
Establishing the specifications for the educational requirements for entry into professional practice at basic and advanced levels
Developing certification processes as measures of professional competence
Certification is a judgment of competence made by nurses who are themselves practicing within the area of specialization. Certification is the formal recognition of the knowledge, skills, abilities, judgment, and experience demonstrated by the achievement of formal criteria identified by the profession. Credentialing boards develop and implement certification examinations and procedures for nurses who wish to have their specialty-practice knowledge recognized by the profession and the public. One component of the required evidence is successful completion of an examination that tests the knowledge base for the selected area of practice. Other requirements relate to the requisite content of course work and the amount of practice hours. Credentialing bodies may elect to use professional portfolios as psychometrically and legally defensible alternatives for certification examinations. Professional portfolios provide a comprehensive and reflective representation of professional abilities, achievements, and efforts.
Contemporary specialty nursing practice is in transition in response to the increasing complexity of care and exponential explosion of data, information, and knowledge. Specialization is a mark of the advancement of the nursing profession and assists in clarifying, revising, and strengthening existing practice. Specialization not only expedites the production of new knowledge and its application in practice, but also provides preparation for teaching and research related to any defined area of nursing. The specialist in nursing practice is evolving to be a nurse who has become expert in a defined area of knowledge and nursing practice through study and supervised practice at the graduate (master’s or doctoral) level.
Legal regulation is the oversight, monitoring, and control of designated professionals, based on applicable statutes and regulations, accompanied by the interpretation of these laws. All nurses are legally accountable for actions taken in the course of professional nursing practice, as well as for actions delegated by the nurse to others assisting in provision of nursing care. Such accountability is accomplished through legal regulatory mechanisms of licensure; granting of authority to practice, such as nurse practice acts; and criminal and civil laws.
The legal contract between society and the professions is defined by statute and by associated rules and regulations. State nurse practice acts and related legislation and regulations serve as the explicit codification of the profession’s obligation to act in the best interests of society. Nurse practice acts grant nurses the authority to practice and grant society the authority to sanction nurses who violate the norms of the profession or act in a manner that threatens the safety of the public.
Statutory definitions of nursing should be compatible with, and build upon, the profession’s definition of its practice base. They must be general enough to provide for the dynamic nature of an evolving scope of nursing practice. Society is best served when consistent definitions of the scope of nursing and of advanced practice nursing are used by each state’s board of nursing and other regulatory bodies. This allows residents of all states to access the full range of nursing services. Multiple stakeholders have established a collaborative effort to garner consensus in this arena.
Institutional Policies and Procedures
Nursing practice occurs within societal institutions, organizations, and settings that have accompanying policies, procedures, rules, and regulations. The scope and standards of practice for nursing and nursing specialties should help guide development of institutional policies and procedures to create a more detailed representation of what constitutes safe, quality, and evidence-based nursing practice.
Self-regulation, which requires personal accountability for the knowledge base for professional practice, is an individual’s demonstrated personal control based on principles, guidelines, and rules deemed important. Nurses develop
and maintain current knowledge, skills, and abilities through formal academic programs and continuing education professional development programs. When available, nurses pursue certification in their area of practice to demonstrate this competence.
FIGURE 6. SELF-DETERMINATION IN THE MODEL OF PROFESSIONAL NURSING PRACTICE REGULATION
Nurses exercise autonomy and freedom within their scope of practice. Autonomy is defined as the capacity of a nurse to determine his or her own actions through independent choice within the full scope of nursing practice (Ballou, 1998). Autonomy and freedom are based on the nurse’s commitment to self-regulation and accountability for practice. In Figure 6, the apex of the pyramid, labeled Self-Determination, represents autonomy, self-regulation, and accountability for practice.
Competence is foundational to autonomy. Nursing competency is an expected level of performance that integrates knowledge, skills, abilities, and judgment (ANA, 2008d). Greater autonomy and freedom in nursing practice are based on broader authority rooted in expert or advanced knowledge in selected areas of nursing. This expert knowledge is associated with greater self-discipline and responsibility for direct care practice and for advancement of the nursing profession. A greater degree of autonomy not only imposes a greater duty to act and to do so competently but also increases accountability.
Nurses also regulate their own practice by participating in peer review. Continuous performance improvement fosters the refinement of knowledge, skills, and clinical decision-making processes at all levels and in all areas of professional nursing practice. As expressed in the profession’s code of ethics, peer review is one mechanism by which nurses are held accountable for practice. As noted in Provision 3.4 (Standards and Review Mechanism) in Code of Ethics for Nurses with Interpretive Statements, nurses should also be active participants in the development of policies and review mechanisms designed to promote patient safety, reduce the likelihood of errors, and address both environmental system factors and human factors that present increased risk to patients. In addition, when errors do occur, nurses are expected to follow established guidelines in reporting committed or observed errors. The focus should be directed to improving systems, rather than projecting blame.
Application of Nursing’s Social Policy Statement
Registered nurses should find the content within Nursing’s Social Policy Statement: The Essence of the Profession pertinent to everyday practice. The description of nursing as a profession valued within society, definition of nursing, presentation of the nursing process, and discussion of regulation set the stage for practice by promoting understanding.
Nursing faculty should find content within this edition of Nursing’s Social Policy Statement that is critical for inclusion in curricula and course materials in undergraduate-, graduate-, and doctoral-level education. Similarly, nurses in professional development roles reinforce the concepts presented in this resource in the practice setting, especially those related to autonomy, competence, scope and standards of nursing practice, and the nursing process.
Students will benefit from reading this statement on nursing’s social policy as they learn about the evolution of their profession through its key attributes: the definition of nursing, the profession’s delineation of the characteristics of a nursing specialty, and the delineation of its scope of practice and accompanying standards and competency statements. The models depicting the nursing process, with its feedback loops and the relationship of the standards of practice and professional performance to the nursing process, will be invaluable in generating improved understanding of the complexity of nursing practice.
Similarly, clear delineation of the six social concerns in health care, and other statements that undergird nursing’s social contract with society, reaffirm the importance of collaboration within nursing and interprofessional healthcare teams. Registered nurses will experience even greater relevance of this content in every practice setting.
Nurse administrators should use this nursing social policy statement as a resource for strategic planning activities, public explanations about nursing and its registered nurses, and the development of vision and mission statements. Members of legal and regulatory bodies and organizations should review this document to understand better how professional, self-, and legal regulation can complement—rather than conflict with—each other. Healthcare consumers may wish to use the social policy statement to understand better the foundation upon which the nursing profession and its registered nurses base their practice.
This social policy statement describes the pivotal nature and role of professional nursing in society and health care. The definition of nursing, introduction of the scope and accompanying standards of professional nursing practice, and discussion of specialization and regulation within the social context in which nurses practice provide an overview of the essence of nursing. Registered nurses focus their specialized knowledge, skills, and caring on improving the health status of the public and ensuring safe, effective, quality care. This statement serves as a resource to assist nurses in conceptualizing their professional practice and provides direction to educators, administrators, and researchers within nursing. This statement also informs other health professionals, legislators and other regulators, funding bodies, and the public about nursing’s social responsibility, accountability, and contribution to health care.
All web-based references were retrieved May 31, 2010.
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American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Nursesbooks.org.
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American Nurses Association. (2008b). ANA’s health system reform agenda. www.nursingworld.org/healthreformagenda
American Nurses Association. (2008c). Professional role competence position statement. http://nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/ANAPositionStatements/practice/PositionStatementProfessionalRoleCompetence.aspx
American Nurses Association. (2008d). Recognition of a nursing specialty, approval of a specialty nursing scope of practice statement, and acknowledgment of specialty nursing standards of practice. Silver Spring, MD: Author.
APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification and education. http://www.nursingworld.org/ConsensusModelforAPRN
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Fowler, Marsha D. M. (Ed.). (2008). Guide to the code of ethics for nurses: Interpretation and application. Silver Spring, MD: Nursesbooks.org.
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Styles, M. M., Schumann, M. J., Bickford, C. J., & White, K. M. (2008). Specialization and credentialing in nursing revisited: Understanding the issues, advancing the profession. Silver Spring, MD: Nursesbooks.org.
Advanced practice registered nurse (APRN)
A certified nurse practitioner, certified registered nurse anesthetist, certified nurse midwife, or clinical nurse specialist who is educationally prepared (usually at a post-bacca-laureate level), accredited by a national accrediting body, and has current certification by a national certifying body in the appropriate APRN role and at least one population focus. See also Population focus; each type of APRN.
The capacity of a nurse to determine his/her own actions through independent choice, including demonstration of competence, within the full scope of nursing practice.
Certified nurse practitioner (CNP)
A registered nurse who is professionally prepared to provide direct primary care and acute care (initial, ongoing, and comprehensive) along the wellness-illness continuum and in all settings. Clinical CNP care includes health promotion, disease prevention, health education, and counseling as well as the diagnosis and management of acute and chronic diseases (APRN Consensus, 2008).
Certified registered nurse anesthetist (CRNA)
A registered nurse who is prepared to provide full-spectrum anesthesia care and anesthesia-related care for individuals across the lifespan, whose health status may range from healthy through all recognized levels of acuity, including persons with immediate, severe, or life-threatening illnesses or injury (APRN Consensus, 2008).
Certified nurse midwife (CNM)
A registered nurse who is prepared to provide primary health care services to women throughout the lifespan, including gynecologic care, family planning services, preconception care, prenatal and postpartum care, childbirth, care of the newborn, and treating the male partner of the female client for sexually transmitted disease and reproductive health (APRN Consensus, 2008).
Clinical nurse specialist (CNS)
A registered nurse who is professionally prepared to integrate care across the continuum and through the patient, nurse, and system spheres of influence. The primary CNS goal is continuous improvement of patient outcomes and nursing care. The CNS is responsible and accountable for diagnosis and treatment of health/illness states, disease management, health promotion, and prevention of illness and risk behaviors (APRN Consensus, 2008).
Code of ethics (nursing)
A set of provisions that makes explicit the primary goals, values, and obligations of the nursing profession and expresses its values, duties, and commitments to the society of which it is a part. In the United States, nurses abide by and adhere to the Code of Ethics for Nurses (ANA, 2001).
A professional healthcare partnership grounded in a reciprocal and respectful recognition and acceptance of each partner’s unique expertise, power, and sphere of influence and responsibilities; the commonality of goals; the mutual safeguarding of the legitimate interest of each party; and the advantages of such a relationship.
An expected and measurable level of nursing performance that integrates knowledge, skills, abilities, and judgment that is based on established scientific knowledge and expectations for nursing practice.
A scholarly and systematic problem-solving paradigm that results in the delivery of high quality health care.
The phenomena of concern to nurses that include any observable need, concern, condition, event, or fact of interest actual or potential health problems.
The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.
Theoretically derived and evidence-based interventions that are intended to protect, promote, and optimize health; prevent illness and injury; alleviate suffering; advocate for individuals, families, communities, and populations; and otherwise produce beneficial outcomes.
The collective professional activities of nurses that are characterized by the interrelations of human responses, theory application, nursing actions, and outcomes.
A critical thinking model comprising the integration of singular, concurrent actions of these six components: assessment, diagnosis, identification of outcomes, planning, implementation, and evaluation.
The results of nursing actions, in relation to identified human responses, based on findings from nursing research, the efficacy and benefit of which are determined by evaluation.
Any one of these six APRN practice areas: family/individual across the life span; adult/gerontology; neonatal; pediatrics; women’s health/gender-related health; psychiatric/mental health.
Registered nurse (RN)
An individual registered or licensed by a state, commonwealth, territory, government, or other regulatory body to practice as a registered nurse.
Regulation of nursing practice
The processes of governance and controls established by authorized bodies as standards, guidelines, protocols, and other mandates for defining, attaining, and maintaining mandated quality of care and practice.
Scope of Nursing Practice
The description of the who, what, where, when, why, and how of nursing practice that addresses the range of nursing practice activities common to all registered nurses. When considered in conjunction with the Standards of Professional Nursing Practice and the Code of Ethics for Nurses, the competent level of nursing common to all registered nurses is comprehensively described.
Authoritative statements by which the nursing profession describes the responsibilities for which its practitioners are accountable, the outcomes for which registered nurses are responsible, and by which the quality of practice, service, or education can be evaluated.
Standards of Practice
The subset of nursing standards that describes a competent level of nursing care as demonstrated by the nursing process that forms the basis for the decision making of registered nurses and that encompasses all significant nursing actions. See also: Nursing process.
Standards of Professional Nursing Practice
The set of nursing standards comprised of the Standards of Practice and the Standards of Professional Performance, with each constituent standard having its own set of key indicators of competence. For a standard to be met, all the listed competencies must be met. When considered in conjunction with the Scope of Nursing Practice, comprehensively describes the competent level of nursing common to all registered nurses.
Standards of Professional Performance
The subset of nursing standards that describes a competent level of activities and behavior in the professional role for the registered nurse by which they are accountable for their professional actions to themselves, their patients, their peers, and society.
A set of interrelated concepts, definitions, or propositions used to systematically describe, explain, predict, or control human responses or phenomena of interest to nurses.
Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education (2008)
The content in this appendix is not current and is of historical significance only.
About the Consensus Model Report
As underscored by the inclusion of APRNs in recent health system reform efforts, there is increased appreciation of the important role that APRNs can play in improving access to quality cost-effective care. However, a proliferation of nursing specializations, debates on appropriate credentials and scope of practice, and a lack of uniformity in state regulations have limited the ability of patients to access APRN care.
The document that is reproduced in this appendix, and that was completed in July 2008 and endorsed by 44 organizations, delineates the model for future regulation of advanced practice registered nurses. This Consensus Model, when implemented, will standardize each aspect of the regulatory process for APRNs, resulting in increased mobility for APRNs and increased access to APRN care.
The document was completed through the collaborative work of the APRN Consensus Workgroup and National Council of State Boards of Nursing APRN Advisory Committee, with extensive input from the larger APRN stakeholder community.
(SOURCE: American Nurses Association, 2009: http://www.nursingworld.org/cmissuebrief)
Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education
July 7, 2008
Completed through the work of the APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee
The APRN Consensus Work Group and the APRN Joint Dialogue Group members would like to recognize the significant contribution to the development of this report made by Jean Johnson, PhD, RN-C, FAAN, Senior Associate Dean, Health Sciences, George Washington School of Medicine and Health Sciences. Consensus could not have been reached without her experienced and dedicated facilitation of these two national, multi-organizational groups.
LIST OF ENDORSING ORGANIZATIONS
This Final Report of the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee has been disseminated to participating organizations. The names of endorsing organizations will be added periodically.
The following organizations have endorsed the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education:
(Posted July 2009)
Academy of Medical-Surgical Nurses (AMSN)
Accreditation Commission for Midwifery Education (ACME)
American Academy of Nurse Practitioners (AANP)
American Academy of Nurse Practitioners Certification Program
American Association of Colleges of Nursing (AACN)
American Association of Critical-Care Nurses (AACN)
American Association of Critical-Care Nurses Certification Corporation
American Association of Legal Nurse Consultants (AALNC)
American Association of Nurse Anesthetists (AANA)
American Board of Nursing Specialties (ABNS)
American College of Nurse-Midwives (ACNM)
American College of Nurse Practitioners (ACNP)
American Holistic Nurses Association (AHNA)
American Midwifery Certification Board (AMCB)
American Nurses Association (ANA)
American Nurses Credentialing Center (ANCC)
American Psychiatric Nurses Association (APNA)
Arkansas State Board of Nursing
Association of Faculties of Pediatric Nurse Practitioners (AFPNP)
Commission on Collegiate Nursing Education (CCNE)
Council on Accreditation of Nurse Anesthesia Educational Programs (COA)
Dermatology Nurses Association (DNA)
Dermatology Nursing Certification Board (DNCB)
Emergency Nurses Association (ENA)
Gerontological Advanced Practice Nurses Association (GAPNA)
Hospice and Palliative Nurses Association (HPNA)
The International Society of Psychiatric Nurses (ISPN)
National Association of Clinical Nurse Specialists (NACNS)
National Association of Orthopedic Nurses (NAON)
National Association of Pediatric Nurse Practitioners (NAPNAP)
National Board for Certification of Hospice and Palliative Nurses (NBCHPN)
National Board on Certification & Recertification of Nurse Anesthetists (NBCRNA)
National Certification Corporation (NCC)
National Council of State Boards of Nursing (NCSBN)
National Gerontological Nursing Association (NGNA)
National League for Nursing (NLN)
National League for Nursing Accrediting Commission, Inc. (NLNAC)
National Organization of Nurse Practitioner Faculties (NONPF)
Nurse Practitioners in Women’s Health (NPWH)
Nurses Organization of Veterans Affairs (NOVA)
Oncology Nursing Certification Corporation (ONCC)
Oncology Nursing Society (ONS)
Orthopedic Nurses Certification Board (ONCB)
Pediatric Nursing Certification Board (PNCB)
Wound, Ostomy and Continence Nurses Society (WOCN)
Wound, Ostomy and Continence Nursing Certification Board (WOCNCB)
Advanced Practice Registered Nurses (APRNs) have expanded in numbers and capabilities over the past several decades with APRNs being highly valued and an integral part of the health care system. Because of the importance of APRNs in caring for the current and future health needs of patients, the education, accreditation, certification and licensure of APRNs need to be effectively aligned in order to continue to ensure patient safety while expanding patient access to APRNs.
APRNs include certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists and certified nurse practitioners. Each has a unique history and context, but shares the commonality of being APRNs. While education, accreditation, and certification are necessary components of an overall approach to preparing an APRN for practice, the licensing boards-governed by state regulations and statutes-are the final arbiters of who is recognized to practice within a given state. Currently, there is no uniform model of regulation of APRNs across the states. Each state independently determines the APRN legal scope of practice, the roles that are recognized, the criteria for entry-into advanced practice and the certification examinations accepted for entry-level competence assessment. This has created a significant barrier for APRNs to easily move from state to state and has decreased access to care for patients.
Many nurses with advanced graduate nursing preparation practice in roles and specialties e.g., informatics, public health, education, or administration) that are essential to advance the health of the public but do not focus on direct care to individuals and, therefore, their practice does not require regulatory recognition beyond the Registered Nurse license granted by state boards of nursing. Like the four current APRN roles, practice in these other advanced specialty nursing roles requires specialized knowledge and skills acquired through graduate-level education. Although extremely important to the nursing profession and to the delivery of safe, high quality patient care, these other advanced, graduate nursing roles, which do not focus on direct patient care, are not roles for Advanced Practice Registered Nurses (APRN) and are not the subject or focus of the Regulatory Model presented in this paper.
The model for APRN regulation is the product of substantial work conducted by the Advanced Practice Nursing Consensus Work Group and the National Council of State Boards of Nursing (NCSBN) APRN Committee. While these groups began work independent of each other, they came together through representatives of each group participating in what was labeled the APRN Joint Dialogue Group. The outcome of this work has been unanimous agreement on most of the recommendations included in this document. In a few instances, when agreement was not unanimous a 66% majority was used to determine the final recommendation. However, extensive dialogue and transparency in the decision-making process is reflected in each recommendation. The background of each group can be found on pages 13-16 and individual and organizational participants in each group in Appendices C-H.
This document defines APRN practice, describes the APRN regulatory model, identifies the titles to be used, defines specialty, describes the emergence of new roles and population foci, and presents strategies for implementation.
Overview of APRN Model of Regulation
The APRN Model of Regulation described will be the model of the future. It is recognized that current regulation of APRNs does not reflect all of the components described in this paper and will evolve incrementally over time. A proposed timeline for implementation is presented at the end of the paper.
In this APRN model of regulation there are four roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), and certified nurse practitioner (CNP). These four roles are given the title of advanced practice registered nurse (APRN). APRNs are educated in one of the four roles and in at least one of six population foci: family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women’s health/gender-related or psych/mental health. APRN education programs, including degree-granting and post-graduate education programs1, are accredited. APRN education consists of a broad-based education, including three separate graduate-level courses in advanced physiology/pathophysiology, health assessment and pharmacology as well as appropriate clinical experiences. All developing APRN education programs or tracks go through a pre-approval, pre-accreditation, or accreditation process prior to admitting students. APRN education programs must be housed within graduate programs that are nationally accredited2 and their graduates must be eligible for national certification used for state licensure.
Individuals who have the appropriate education will sit for a certification examination to assess national competencies of the APRN core, role and at least one population focus area of practice for regulatory purposes. APRN certification programs will be accredited by a national certification accrediting body3. APRN certification programs will require a continued competency mechanism.
Individuals will be licensed as independent practitioners for practice at the level of one of the four APRN roles within at least one of the six identified population foci. Education, certification, and licensure of an individual must be congruent in terms of role and population foci. APRNs may specialize but they cannot be licensed solely within a specialty area. In addition, specialties can provide depth in one’s practice within the established population foci. Education and assessment strategies for specialty areas will be developed by the nursing profession, i.e., nursing organizations and special interest groups. Education for a specialty can occur concurrently with APRN education required for licensure or through post-graduate education. Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by the professional organizations.