Scope of Nursing Practice
Definition of Nursing
Nursing’s Social Policy Statement: The Essence of the Profession (ANA, 2010, p. 3) builds on previous work and provides the following contemporary definition 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.
This definition serves as the foundation for the following expanded description of the Scope of Nursing Practice and the Standards of Professional Nursing Practice.
Professional Nursing’s Scope and Standards of Practice
A professional nursing organization has a responsibility to its members and to the public it serves to develop the scope and standards of its profession’s practice. As the professional organization for all registered nurses, the American Nurses Association (ANA) has assumed the responsibility for developing the scope and standards that apply to the practice of all professional nurses and serve as a template for nursing specialty practice. Standards do, however, belong
to the profession and, thus, require broad input into their development and revision. Nursing: Scope and Standards of Practice, Second Edition, describes a competent level of nursing practice and professional performance common to all registered nurses.
Description of the Scope of Nursing Practice
The scope of practice statement describes the “who,” “what,” “where,” “when,” “why,” and “how” of nursing practice. Each of these questions must be answered to provide a complete picture of the dynamic and complex practice of nursing and its evolving boundaries and membership. The profession of nursing has one scope of practice that encompasses the full range of nursing practice, pertinent to general and specialty practice. The depth and breadth in which individual registered nurses engage in the total scope of nursing practice are dependent on their education, experience, role, and the population served.
Development and Function of Nursing Standards
The Standards of Professional Nursing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. The standards published herein may serve as evidence of the standard of care, with the understanding that application of the standards depends on context. The standards are subject to change with the dynamics of the nursing profession, as new patterns of professional practice are developed and accepted by the nursing profession and the public. In addition, specific conditions and clinical circumstances may also affect the application of the standards at a given time, e.g., during a natural disaster. The standards are subject to formal, periodic review and revision.
The Function of Competencies in Standards
The competencies that accompany each standard may be evidence of compliance with the corresponding standard. The list of competencies is not exhaustive. Whether a particular standard or competency applies depends upon the circumstances. For example, a nurse providing treatment to an unconscious, critical patient who presented to the hospital by ambulance without family has a duty to collect comprehensive data pertinent to the patient’s health (Standard 1. Assessment). However, under the attendant circumstances, that nurse may not be expected to assess family dynamics and impact on the patient’s health and wellness (Assessment Competency). In the same circumstance, Standard 5B. Health Teaching and Health Promotion may not apply at all.
The Nursing Process
The nursing process is often conceptualized as the integration of singular actions of assessment, diagnosis, and identification of outcomes, planning, implementation, and finally, evaluation. The nursing process in practice is not linear as often conceptualized, with a feedback loop from evaluation to assessment. Rather, it relies heavily on the bi-directional feedback loops from each component, as illustrated in Figure 1.
The Standards of Practice coincide with 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 (ANA, 2010). Five tenets characterize contemporary nursing practice (see next two pages).
FIGURE 1. The Nursing Process and Standards of Professional Nursing Practice
Tenets Characteristic of Nursing Practice.
1. Nursing practice is individualized.
Nursing practice respects diversity and is individualized to meet the unique needs of the healthcare consumer or situation. Healthcare consumer is defined to be the patient, person, client, family, group, community, or population who is the focus of attention and to whom the registered nurse is providing services as sanctioned by the state regulatory bodies.
2. Nurses coordinate care by establishing partnerships.
The registered nurse establishes partnerships with persons, families, support systems, and other providers, utilizing in-person and electronic communications, to reach a shared goal of delivering health care. Health care is defined as the attempt “to address the health needs of the patient and the public” (ANA, 2001, p. 10). Collaborative interprofessional team planning is based on recognition of each discipline’s value and contributions, mutual trust, respect, open discussion, and shared decision-making.
3. Caring is central to the practice of the registered nurse.
Professional nursing promotes healing and health in a way that builds a relationship between nurse and patient (Watson, 1999, 2008). “Caring is a conscious judgment that manifests itself in concrete acts, interpersonally, verbally, and nonverbally” (Gallagher-Lepak & Kubsch, 2009, p. 171). While caring for individuals, families, and populations is the key focus of nursing, the nurse additionally promotes self-care as well as care of the environment and society (Hagerty, Lynch-Sauer, Patusky, & Bouwseman, 1993).
4. Registered nurses use the nursing process to plan and provide individualized care to their healthcare consumers.
Nurses use theoretical and evidence-based knowledge of human experiences and responses to collaborate with healthcare consumers to assess, diagnose, identify outcomes, plan, implement, and evaluate care. Nursing interventions are intended to produce beneficial effects, contribute to quality outcomes, and above all, do no harm. Nurses evaluate the effectiveness of their care in relation to identified outcomes and use evidence-based practice to improve care (ANA, 2010).
Critical thinking underlies each step of the nursing process, problem-solving, and decision-making. The nursing process is cyclical and dynamic, interpersonal and collaborative, and universally applicable.
5. A strong link exists between the professional work environment and the registered nurse’s ability to provide quality health care and achieve optimal outcomes.
Professional nurses have an ethical obligation to maintain and improve healthcare practice environments conducive to the provision of quality health care (ANA, 2001). Extensive studies have demonstrated the relationship between effective nursing practice and the presence of a healthy work environment. Mounting evidence demonstrates that negative, demoralizing, and unsafe conditions in the workplace (unhealthy work environments) contribute to medical errors, ineffective delivery of care, and conflict and stress among health professionals.
Healthy Work Environments for Nursing Practice
ANA supports the following models of healthy work environment design:
AMERICAN ASSOCIATION OF CRITICAL-CARE NURSES
The American Association of Critical-Care Nurses has identified six standards for establishing and maintaining healthy work environments (AACN, 2005):
Nurses must be as proficient in communication skills as they are in clinical skills.
Nurses must be relentless in pursuing and fostering a sense of team and partnership across all disciplines.
Nurses are seen as valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.
Staffing must ensure the effective match between healthcare consumer needs and nurse competencies.
Nurses must be recognized and must recognize others for the value each brings to the work of the organization.
Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in achieving it.
MAGNET RECOGNITION PROGRAM
The Magnet Recognition Program® addresses the professional work environment, requiring that Magnet®-designated facilities adhere to the following model components (ANCC, 2008):
The transformational leader leads people where they need to be in order to meet the demands of the future.
Structures and processes developed by influential leadership provide an innovative practice environment in which strong professional practice flourishes and the mission, vision, and values come to life to achieve the outcomes believed to be important for the organization.
Exemplary Professional Practice
This demonstrates what professional nursing practice can achieve.
New Knowledge, Innovation, and Improvements Organizations have an ethical and professional responsibility to contribute to healthcare delivery, the organization, and the profession.
Empirical Quality Results
Organizations are in a unique position to become pioneers of the future and to demonstrate solutions to numerous problems inherent in today’s healthcare systems. Beyond the “What” and “How,” organizations must ask themselves what difference these efforts have made
INSTITUTE OF MEDICINE
The Institute of Medicine has also reported that safety and quality problems occur when dedicated health professionals work in systems that neither support them nor prepare them to achieve optimal patient care outcomes (IOM, 2004). Such rapid changes as reimbursement modification and cost containment efforts, new healthcare technologies, and changes in the healthcare workforce have influenced the work and work environment of nurses. Accordingly, concentration on key aspects of the work environment—people, physical surroundings, and tools—can enhance healthcare working conditions and improve patient safety. These include:
Transformational leadership and evidence-based management
Maximizing workforce capability
Creating and sustaining a culture of safety and research
Work space design and redesign to prevent and mitigate errors
Effective use of telecommunications and biomedical device interoperability
Model of Professional Nursing Practice Regulation
In 2006 the Model of Professional Nursing Practice Regulation (see Figure 2) emerged from ANA work and informed the discussions of specialty nursing and advanced practice registered nurse practice.
The lowest level in the model represents the responsibility of the professional and specialty nursing organizations to their members and the public to define the scope and standards of practice for nursing.
The next level up the pyramid represents the regulation provided by the nurse practice acts and the rules and regulations in the pertinent licensing jurisdictions. Institutional policies and procedures provide further considerations in the regulation of nursing practice for the registered nurse and advanced practice registered nurse.
FIGURE 2. Model of Professional Nursing Practice Regulation (Styles et al., 2008).
Note that the highest level is that of self determination by the nurse after consideration of all the other levels of input about professional nursing practice regulation. The outcome is safe, quality, and evidence-based practice.
Standards of Professional Nursing Practice
The Standards of Professional Nursing Practice content consists 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. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse’s decision-making.
STANDARD 1. ASSESSMENT
The registered nurse collects comprehensive data pertinent to the healthcare consumer’s health and/or the situation.
STANDARD 2. DIAGNOSIS
The registered nurse analyzes the assessment data to determine the diagnoses or the issues.
STANDARD 3. OUTCOMES IDENTIFICATION
The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.
STANDARD 4. PLANNING
The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
STANDARD 5. IMPLEMENTATION
The registered nurse implements the identified plan.
STANDARD 5A. COORDINATION OF CARE
The registered nurse coordinates care delivery.
STANDARD 5B. HEALTH TEACHING AND HEALTH PROMOTION
The registered nurse employs strategies to promote health and a safe environment.
STANDARD 5C. CONSULTATION
The graduate-level prepared specialty nurse or advanced practice registered nurse provides consultation to influence the identified plan, enhance the abilities of others, and effect change.
STANDARD 5D. PRESCRIPTIVE AUTHORITY AND TREATMENT
The advanced practice registered nurse uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations.
STANDARD 6. EVALUATION
The registered nurse evaluates progress toward attainment of outcomes.
Standards of Professional Performance
The Standards of Professional Performance describe a competent level of behavior in the professional role, including activities related to ethics, education, evidence-based practice and research, quality of practice, communication, leadership, collaboration, professional practice evaluation, resource utilization, and environmental health. All registered nurses are expected to engage in professional role activities, including leadership, appropriate to their education and position. Registered nurses are accountable for their professional actions to themselves, their healthcare consumers, their peers, and ultimately to society.
STANDARD 7. ETHICS
The registered nurse practices ethically.
STANDARD 8. EDUCATION
The registered nurse attains knowledge and competence that reflects current nursing practice.
STANDARD 9. EVIDENCE-BASED PRACTICE AND RESEARCH
The registered nurse integrates evidence and research findings into practice.
STANDARD 10. QUALITY OF PRACTICE
The registered nurse contributes to quality nursing practice.
STANDARD 11. COMMUNICATION
The registered nurse communicates effectively in all areas of practice.
STANDARD 12. LEADERSHIP
The registered nurse demonstrates leadership in the professional practice setting and the profession.
STANDARD 13. COLLABORATION
The registered nurse collaborates with healthcare consumer, family, and others in the conduct of nursing practice.
STANDARD 14. PROFESSIONAL PRACTICE EVALUATION
The registered nurse evaluates her or his own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations.
STANDARD 15. RESOURCE UTILIZATION
The registered nurse utilizes appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible.
STANDARD 16. ENVIRONMENTAL HEALTH
The registered nurse practices in an environmentally safe and healthy manner.
Professional Competence in Nursing Practice
The public has a right to expect registered nurses to demonstrate professional competence throughout their careers. The registered nurse is individually responsible and accountable for maintaining professional competence. It is the nursing profession’s responsibility to shape and guide any process for assuring nurse competence. Regulatory agencies define minimal standards of competency to protect the public. The employer is responsible and accountable to provide a practice environment conducive to competent 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, 2008).
ANA believes that in the practice of nursing competence can be defined, measured, and evaluated. No single evaluation method or tool can guarantee competence. Competence is situational and dynamic; it is both an outcome and an ongoing process. Context determines what competencies are necessary.
Definitions and Concepts Related to Competence
A number of terms are central to the discussion of competence:
An individual who demonstrates “competence” is performing at an expected level.
A competency is an expected level of performance that integrates knowledge, skills, abilities, and judgment.
The integration of knowledge, skills, abilities, and judgment occurs in formal, informal, and reflective learning experiences.
Knowledge encompasses thinking, understanding of science and humanities, professional standards of practice, and insights gained from context, practical experiences, personal capabilities, and leadership performance.
Skills include psychomotor, communication, interpersonal, and diagnostic skills.
Ability is the capacity to act effectively. It requires listening, integrity, knowledge of one’s strengths and weaknesses, positive self-regard, emotional intelligence, and openness to feedback.
Judgment includes critical thinking, problem solving, ethical reasoning, and decision-making.
Formal learning most often occurs in structured, academic, and professional development practice environments, while informal learning can be described as experiential insights gained in work, community, home, and other settings.
Reflective learning represents the recurrent thoughtful personal self-assessment, analysis, and synthesis of strengths and opportunities for improvement. Such insights should lead to the creation of a specific plan for professional development and may become part of one’s professional portfolio (ANA, 2008).
Competence and Competency in Nursing Practice
Competent registered nurses can be influenced by the nature of the situation, which includes consideration of the setting, resources, and the person. Situations can either enhance or detract from the nurse’s ability to perform. The registered nurse influences factors that facilitate and enhance competent practice. Similarly, the nurse seeks to deal with barriers that constrain competent practice. The expected level of performance reflects variability depending upon context and the selected competence framework or model.
The ability to perform at the expected level requires a process of lifelong learning. Registered nurses must continually reassess their competencies and identify needs for additional knowledge, skills, personal growth, and integrative learning experiences.
“Competence in nursing practice must be evaluated by the individual nurse (self-assessment), nurse peers, and nurses in the roles of supervisor, coach, mentor, or preceptor. In addition, other aspects of nursing performance may be evaluated by professional colleagues and patients.
Competence can be evaluated by using tools that capture objective and subjective data about the individual’s knowledge base and actual performance and are appropriate for the specific situation and the desired outcome of the competence evaluation … However, no single evaluation tool or method can guarantee competence” (ANA, 2008, p. 6).
Professional Registered Nurses Today
In 2008, there were an estimated 3 million registered nurses (RNs) in the United States, of which 2.6 million are currently employed. The majority of registered nurses initially entered nursing with an associate degree; however, the percentage of nurses entering practice with a bachelor’s degree or higher has increased steadily. Most registered nurses work in hospitals (62%) and identify themselves as “staff nurses” (66%).
In addition to hospitals, nurses report working in ambulatory care (10%), public/community health (7.8%), home health (6.4%), nursing home/extended care (5.3%), academic education (3.8%), and other areas, including insurance, benefits, and utilization review (3.9%). Public/community health includes school and occupational health settings, and ambulatory care includes medical and physician practices, health centers and clinics, and other types of non-hospital clinic settings.
About 9% of nurses identify themselves as one of the four recognized advanced practice registered nurse roles, and other identified roles include management, patient coordinator, instructor, patient educator, and researcher. (U.S. Dept. of Labor, 2010; U.S. DHHS, 2010)
Licensure and Education of Registered Nurses
The registered nurse is licensed and authorized by a state, commonwealth, or territory to practice nursing. Professional licensure of the healthcare professions is established by each jurisdiction to protect the public safety and authorize the practice of the profession. Because of this, the requirements for RN licensure and advanced practice nursing vary widely.
The registered nurse is educationally prepared for competent practice at the beginning level upon graduation from an accredited school of nursing and qualified by national examination for RN licensure. ANA has consistently affirmed the baccalaureate degree in nursing as the preferred educational preparation for entry into nursing practice.
The registered nurse is educated in the art and science of nursing, with the goal of helping individuals and groups attain, maintain, and restore health whenever possible. Experienced nurses may become proficient in one or more practice areas or roles. These nurses may concentrate on healthcare consumer care in clinical nursing practice specialties. Others influence nursing and support the direct care rendered to healthcare consumers by those professional
nurses in clinical practice. Credentialing is one form of acknowledging such specialized knowledge and experience. Credentialing organizations may mandate specific nursing educational requirements, as well as timely demonstrations of knowledge and experience in specialty practice.
Registered nurses may pursue advanced academic studies to prepare for specialization in practice. Educational requirements vary by specialty and educational program. New models for educational preparation are evolving in response to the changing healthcare, education, and regulatory practice environments.
Roots of Professional Nursing
Nursing has evolved into a profession with a distinct body of knowledge, university-based education, specialized practice, standards of practice, a social contract (ANA, 2010), and an ethical code (ANA, 2001). With this grounding, registered nurses and their profession are concerned with the availability and accessibility of nursing care to healthcare consumers, families, communities, and populations, and seek to ensure the integrity of nursing practice in all current and future healthcare systems. This professional evolution is described in the following pages.
Nursing Research and Evidence-Based Practice
Contemporary nursing practice has its historical roots in the poorhouses, the battlefields, and the industrial revolutions in nineteenth-century Europe and America. Initially nurses trained in hospital-based nursing schools and were employed mainly providing private care to patients in their homes. Florence Nightingale provided a foundation for nursing and the basis for autonomous nursing practice as distinct from medicine. Nightingale also is credited with identifying the importance of collecting empirical evidence, the underpinning of nursing’s current emphasis on evidence-based practice, “What you want are facts, not opinions … The most important practical lesson that can be given to nurses is to teach them what to observe—how to observe—what symptoms indicate improvement—which are of none—which are the evidence of neglect—and what kind of neglect.” (Nightingale, 1859, p. 105)
Although Nightingale recommended clinical nursing research in the mid-1800s, nurses did not follow her advice for over 100 years. Nursing research was able to flourish only as nurses received advanced educational preparation.
In the early 1900s nurses received their advanced degrees in nursing education, and thus nursing research was limited to studies of nurses and nursing education. However, case studies on nursing interventions were conducted in the 1920s and 1930s and the results published in the American Journal of Nursing.
In the 1950s, interest in nursing care studies began to rise. In 1952, the first issue of Nursing Research was published. In the 1960s, nursing studies began to explore theoretical and conceptual frameworks as a basis for practice. By the 1970s, more doctorally prepared nurses were conducting research, especially studies related to practice and the improvement of patient care. By the 1980s, there were greater numbers of qualified nurse researchers than ever before, and more computers available for collection and analysis of data. In 1985, the National Center for Nursing Research was established within the National Institutes of Health, putting nursing research into the mainstream of health research (Grant and Massey, 1999).
In the last half of the twentieth century, nurse researchers (1950s) and nurse theorists (1960s and 1970s) greatly contributed to the expanding body of nursing knowledge with their studies of nursing practice and the development of nursing models and theories. These conceptual models and theories borrow from other disciplines such as sociology, psychology, biology, and physics.
For example, the work of Neuman and King makes extensive use of systems theory. There is also Levine’s conservation model, Roger’s science of unitary human beings, Roy’s adaptation model, Orem’s self-care model, Peplau’s interpersonal relations model, and Watson’s theory of caring. The 1980s brought revisions to these theories, as well as additional theories developed by nursing leaders, such as Johnson, Parse, and Leininger, that added to the theoretical basis of nursing (George, 2002). In the 1990s, research tested and expanded these theories, which in turn continued to define and elaborate the discipline of nursing.
Evidence-based practice (EBP) is a scholarly and systematic problem-solving paradigm that results in the delivery of high-quality health care. In order to make the best clinical decisions using EBP, external evidence from research is blended with internal evidence (i.e., practice-generated data), clinical expertise, and healthcare consumer values and preferences to achieve the best outcomes for individuals, groups, populations, and healthcare systems.
Nursing’s embrace of EBP is part of a larger call to integrate it into the entire spectrum of healthcare disciplines and professions. The Institute of Medicine (IOM) developed a vision for clinical education in the health professions that is centered on a commitment to meeting patient needs (IOM, 2003). This report
stresses that all health disciplines must embrace evidence-based practice, quality improvement, and informatics in delivering healthcare consumer-centered care, and that their education should reflect and teach them to value those competencies. Interprofessional team collaboration is necessary to achieve quality outcomes for the improvement of health care.
Nursing research and EBP contribute to the body of knowledge and enhance outcomes. As a profession, nursing continually evaluates and applies nursing research findings. Evaluation of outcomes is a critical step in EBP. New knowledge is translated to healthcare consumer care to promote effective and efficient care and improved outcomes. It is then disseminated to decrease practice variations, improve outcomes, and create standards of excellence for care and policies. In addition, nurses ensure that changes in practice are based on current evidence; they should have expert resources in their practice environment and seek out those resources to assist them with specific steps in EBP.
The complex dynamics of health care, and demands for healthcare reform, will challenge the profession to quantify and qualify the value of nursing and nursing care. In alignment with the current edition of Nursing’s Social Policy Statement (ANA, 2010) and this publication, the nursing profession continually examines nursing practice. An example is the study of unit-based nurse staffing levels, and demonstrating through evidence that safe staffing is imperative to quality patient care. This includes ongoing systematic evaluation of the impact of staffing and staffing effectiveness on patient outcomes.
Nursing’s foundation as a profession took shape in the nineteenth century under Florence Nightingale, most notably with her work to provide quality nursing care for British soldiers during the Crimean War. But Nightingale also encouraged nurses to care for people beyond the sick bed, and to improve the health and safety of communities to promote wellness and prevent death (Nightingale, 1859). In the succeeding 150 years, nursing has expanded to almost every theater of health care.
Specialty Practice in Nursing
Nursing first expanded into public health interventions on behalf of at-risk communities and vulnerable populations. In 1893, Lillian Wald pioneered public health nursing at the Henry Street Settlement House in New York City. In 1899, Teacher’s College at Columbia University offered the first university program for graduate nurses to specialize in public health nursing (Stewart, 1948). An editorial in the American Journal of Nursing in 1911 pointed out
the urgent demand for nurses who could teach others and who could organize a whole community.
In the mid-twentieth century and beyond, advances in medical treatment and healthcare technology led to the evolution of other nursing specialties. Specialized education, training, and certification ensued in both traditional and newer areas of clinical practice, including medical-surgical nursing, pediatrics, anesthesia, midwifery, emergency care, mental health, public health, critical care, neonatal care, and primary care.
The continuation of the profession depends on the education of nurses, appropriate organization of nursing services, continued expansion of nursing knowledge, and the development and adoption of policies. Such initiatives demand that registered nurses be adequately prepared for these nursing specialties. Some specialties reflect the intersection of nursing’s body of knowledge and that of another profession or discipline, directly influence nursing practice, and support the delivery of direct care rendered by registered nurses to healthcare consumers. Specialty nurses collaborate, consult, and serve as a liaison, bridging the role of the professional registered nurse with that of other professionals, and subsequently help to delineate nursing’s role in society.
Registered nurses in specialty practice represent the full spectrum from novice to expert. Many nurses with an advanced graduate nursing education practice in specialties, such as informatics, public health, education, or administration, that are essential to advancing the public health but do not focus on direct care to individuals. Therefore, their practice does not require regulatory recognition beyond the Registered Nurse license granted by state boards of nursing.
Similarly, advanced practice registered nurses acquire specialized knowledge and skills through graduate-level education in their selected specialty areas. Competencies in individual specialty areas of practice are defined by separate specialty scope and standards documents, authored by specialty nursing associations. Many specialty nursing organizations recognize individual expertise through national certification in the specialty (see pages 92-94).
Advanced Practice Registered Nurse Roles
Another evolution of nursing practice was the development of educational programs to prepare nurses for advanced practice in direct care roles. These Advanced Practice Registered Nurse (APRN) roles include Certified Registered Nurse Anesthetists (CRNAs), Certified Nurse-Midwives (CNMs), Clinical
Nurse Specialists (CNSs), and Certified Nurse Practitioners (CNPs). Each has a unique history and context, but shares a focus on direct care to individual healthcare consumers.
Advanced Practice Registered Nurse is a regulatory title and includes the four roles listed above. The core competencies for education and the scope of practice are defined by the professional associations. State law and regulation further define criteria for licensure for the designated scopes of practice. The need to ensure healthcare consumer safety and access to APRNs by aligning education, accreditation, licensure, and certification is shown in Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (APRN JDG, 2008).
In addition to the licensure, accreditation, certification, and education requirements for advanced practice registered nurses outlined in the Consensus Model, professional organizations have established standards and competencies for each advanced practice role:
Accreditation Commission for Midwifery Education: Criteria for Programmatic Accreditation (2010)
American Academy of Nurse Practitioners: Standards of Practice for Nurse Practitioners (2007)
American Association of Nurse Anesthetists: Scope and Standards for Nurse Anesthesia Practice (2007)
American College of Nurse-Midwives:
Core Competencies for Basic Midwifery Practice (2008)
Standards for the Practice of Midwifery (2009)
Council on Accreditation of Nurse Anesthesia Educational Programs: Competencies and Curricular Models (2009)
National Organization of Nurse Practitioner Faculties: Domains and Core Competencies of Nurse Practitioner Practice (2006)
National Association of Clinical Nurse Specialists:
Organizing Framework and CNS Core Competencies (2008)
Core Practice Doctorate Clinical Nurse Specialist (CNS) Competencies (2009)
Nurses in Advocacy and Society
Advocacy is a fundamental aspect of nursing practice. Registered nurses have long served as healthcare consumer advocates and used grassroots networking to influence social and political leaders and other advocates. Registered nurses firmly believe it is their obligation to help improve societal conditions related to healthcare consumer care, health, and wellness. Such issues have included protective labor laws, minimum wage, communicable disease programs, immunizations, well-baby and child care, women’s health, curbing violence, reproductive health, end-of-life care, universal health care, social security, Medicare and Medicaid, the financing and reimbursement of health care, healthcare reform, ethics, mental health parity, confidentiality, workplace safety, and healthcare consumer rights.
There is ample need for professional nurses to continue advocacy and lobbying. These efforts include the evaluation and restructuring of health care, reimbursement and value of nursing care, funding for nursing education, the role of nursing in health and medical homes, comparative effectiveness, and advances in health information technology. Nurses will continue to remain strong advocates for healthcare consumers, their care, and health care.
The Progression of Nursing Education
ANA’s long-held position is that the baccalaureate degree is the entry degree into nursing. But nursing’s educational track to professional and career growth is not linear, and while there is an explicit progression of educational degrees, there is considerable flexibility in how the progression is achieved. Educational bodies are establishing entry-into-practice master’s programs, associate’s degree to baccalaureate or master’s degree programs, and most notably second-degree baccalaureate programs.
Two new degrees have been introduced by the American Association of Colleges of Nursing (AACN) since 2004. The Doctor of Nursing Practice (DNP) was proposed as a generic clinical degree associated with practice-based nursing, and has been proposed by AACN to be the graduate degree for advanced nursing practice or specialty preparation by 2015 (AACN, 2004). The second degree is the Clinical Nurse Leader (CNL), described as an “advanced generalist” educated at the graduate level. A defining feature of the CNL role is an emphasis on health promotion, risk reduction, and population-based health care (AACN, 2008).
IOM Influences on the Quality and Environment of Nursing Practice
To address issues in health care, the Institute of Medicine, a branch of the National Academy of Sciences, commissions reports on specific topics. While the IOM does not necessarily represent nursing, it does involve nurses in its work. Its reports and other publications are directed to universal medical practice, and sometimes explicitly to nursing, and provide a framework for systematic positive change in healthcare services.
In 1999, the Quality of Health Care in America Committee released the first and arguably most pivotal report, To Err is Human: Building a Safer Health System, which suggests that harm done to healthcare consumers in a profession that strives to “First, do no harm” is unacceptable. One of the most influential and paradigm-shifting conclusions of the report was that individuals and reckless behavior played only a small part in patient safety violations, and that faulty systems in which people were set up for failure were more problematic.
A second report by the committee in 2001, Crossing the Quality Chasm: A New Health System for the 21st Century, urges a fundamental, sweeping redesign of the entire health system. Incremental change was not enough. The committee suggested that such a system would not only improve patient safety and quality outcomes, but would also retain more health professionals who felt their contributions were making a satisfactory impact on those under their care.
Keeping Patients Safe: Transforming the Work Environment of Nurses is a key report for nurses; it considers how their interaction with their workplace helps or hinders patient care. The report reviews evidence on the work and work environments of nurses, and takes into account the behavioral traits of nurses, the organizational practices and culture, and the structural and engineering traits of the workplace. The report identifies components of the workplace most influential on nursing and patient outcomes—leadership and management, the workforce, work processes, and organizational culture—and proposes changes to these components that would lead to better outcomes for patients and nurses (IOM, 2004).
The connection between the nurse’s work environment and patient mortality and failure to rescue was demonstrated by Aiken et al. (2008). Patients in hospitals with a better practice environment (characterized by nursing foundations for quality of care, nurse manager ability, leadership, and support, and collegial nurse-physician relations) fared far better than patients in
hospitals with poor practice environments. To date, few work environments have achieved all of the IOM recommendations from 2004. The healthcare industry must alter the work environment of nurses to allow them to meet their social responsibility for healthcare consumer safety.
Integrating the Science and Art of Nursing
Nursing is a learned profession built on a core body of knowledge that reflects its dual components of science and art. Nursing requires judgment and skill based on principles of the biological, physical, behavioral, and social sciences. Nursing is a scientific discipline as well as a profession. Registered nurses employ critical thinking to integrate objective data with knowledge gained from an assessment of the subjective experiences of healthcare consumers. Registered nurses use critical thinking to apply the best available evidence and research data to diagnosis and treatment. Nurses continually evaluate quality and effectiveness of nursing practice and seek to optimize outcomes.
The Science of Nursing
The science of nursing is based on an analytical framework of critical thinking known as the nursing process, comprised of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. These steps serve as the foundation of clinical decision-making and support evidence-based practice. Wherever they practice, registered nurses use the nursing process and other types of critical thinking to respond to the needs of the populations they serve, and use strategies that support optimal outcomes most appropriate to the healthcare consumer or situation, being mindful of resource utilization.
Nurses as scientists rely on evidence to guide their policies and practices, but also as a way of quantifying the nurses’ impact on the health outcomes of healthcare consumers. An example of ANA leadership in this area is the National Database of Nursing Quality Indicators (NDNQI®), a repository for nursing-sensitive indicators. NDNQI is the only database containing data collected at the nursing unit level.
The Art of Nursing
The art of nursing is based on caring and respect for human dignity. A compassionate approach to patient care carries a mandate to provide that care competently. Competent care is provided and accomplished through both independent practice and partnerships. Collaboration may be with other colleagues or with the individuals seeking support or assistance with their healthcare needs. Central to the nursing practice is the art of caring, which is represented in the personal relationship that the nurse enters with the patient. The art of caring goes beyond the emotional connections of humans to the ability to respond to the human aspects of health and illness within the critical moment to promote healing and calm (Watson 1999, 2008).
The art of nursing embraces dynamic processes that affect the human person, including, for example, spirituality, healing, empathy, mutual respect, and compassion. These intangible aspects foster health. Nursing embraces healing. Healing is fostered by compassion, helping, listening, mentoring, coaching, teaching, exploring, being present, supporting, touching, intuition, empathy, service, cultural competence, tolerance, acceptance, nurturing, mutually creating, and conflict resolution.
Nursing focuses on the promotion and maintenance of health and the prevention or resolution of disease, illness, or disability. The nursing needs of human beings are identified from a holistic perspective and are met in the context of a culturally sensitive, caring, personal relationship. Nursing includes the diagnosis and treatment of human responses to actual or potential health problems. Registered nurses employ practices that are restorative, supportive, and promotive in nature.
Restorative practices modify the impact of illness or disease.
Supportive practices are oriented toward modification of relationships or the practice environment to support health.
Promotive practices mobilize healthy patterns of living, foster personal and family development, and support self-defined goals of individuals, families, communities, and populations.
Nursing’s Societal and Ethical Dimensions
Nursing is responsive to the changing needs of society and the expanding knowledge base of its theoretical and scientific domains. One of nursing’s objectives is to achieve positive healthcare consumer outcomes that maximize one’s quality of life across the entire lifespan. Registered nurses facilitate the interprofessional and comprehensive care provided by healthcare professionals, paraprofessionals, and volunteers. In other instances, nurses engage in consultation with other colleagues to inform decision-making and planning to meet healthcare consumer needs. Registered nurses often participate in interprofessional teams in which the overlapping skills complement each member’s individual efforts.
All nursing practice, regardless of specialty, role, or setting, is fundamentally independent practice. Registered nurses are accountable for nursing judgments made and actions taken in the course of their nursing practice. Therefore, the registered nurse is responsible for assessing individual competence and is committed to the process of lifelong learning. Registered nurses develop and maintain current knowledge and skills through formal and continuing education and seek certification when it is available in their areas of practice.
Registered nurses are bound by a professional code of ethics (ANA, 2001) and regulate themselves as individuals through a collegial process of peer review of practice. Peer evaluation fosters the refinement of knowledge, skills, and clinical decision-making at all levels and in all areas of clinical practice. Self-regulation by the profession of nursing assures quality of performance, which is the heart of nursing’s social contract (ANA, 2010).
Registered nurses and members of various professions exchange knowledge and ideas about how to deliver high-quality health care, resulting in overlaps and constantly changing professional practice boundaries. This interprofessional team collaboration involves recognition of the expertise of others within and outside one’s profession and referral to those providers when appropriate. Such collaboration also involves some shared functions and a common focus on one overall mission. By necessity, nursing’s scope of practice has flexible boundaries.
Registered nurses regularly evaluate safety, effectiveness, and cost in the planning and delivery of nursing care. Nurses recognize that resources are limited and unequally distributed, and that the potential for better access to care requires innovative approaches, such as treating healthcare consumers
remotely. As members of a profession, registered nurses work toward equitable distribution and availability of healthcare services throughout the nation and the world.
Caring and Nursing Practice
The essence of nursing practice is caring. “It is a beautiful and mysterious power that one human being can have on another through the mere act of caring… A great truth, the act of caring is the first step in the power to heal.” (Moffitt, in Relationship-Based Care, 2004).
Watson (1999, 2008) emphasizes the personal relationship between patient and nurse. She highlights the role of the nurse in defining the patient as a unique human being and stresses the importance of the connections between the nurse and patient, modeled in her Transpersonal Caring-Healing Framework.
Leininger (1988) considers care for people from a broad range of cultures. Her five theoretical assumptions on caring are:
Care is essential for human growth and survival, and to face death.
There can be no curing without caring.
Expressions of care vary among all cultures of the world.
Therapeutic nursing care can only occur when cultural care values, expressions, or practices are known and used explicitly.
Nursing is a transcultural care profession and discipline.
Swanson (1993) builds on Watson’s framework and describes five caring processes and specific techniques for putting them into practice. The first two processes are internal processes of providing care; the other three are action processes.
Maintaining Belief: Maintaining belief in persons and their capacity to make it through events and transitions
Knowing: Striving to understand an event as it has meaning in the life of the other
Being With: Being emotionally present to the other
Doing For: Doing for the other what they would do for themselves if it were possible
Enabling and Informing: Facilitating the other’s passage through life transitions and unfamiliar events
Continued Commitment to the Profession
A continued commitment to the nursing profession requires a nurse to remain involved in continuous learning and strengthening individual practice within varied practice settings. This may include civic activities, membership in and support of professional associations, collective bargaining, and workplace advocacy. The code of ethics (ANA, 2001) serves as the ethical framework in nursing regardless of practice setting or role, and provides guidance for the future.
Nurses promote the health of the individual and society regardless of cultural background, value system, religious belief, gender, sexual identity, or disability. Nurses commit to their profession by utilizing their skills, knowledge, and abilities to act as visionaries, promoting safe practice environments, and supporting resourceful, accessible, and cost-effective delivery of health care to serve the ever-changing needs of the population.
Professional Trends and Issues
Despite spending more on health care than any other nation, the United States ranks 42nd in the world in life expectancy (Trust for America’s Health, 2009). A reformed healthcare system focused on primary care, prevention, and chronic disease management can alleviate the financial and social costs of treating preventable and chronic diseases. Interprofessional teams and coordination of care across the illness trajectory will be key components in the new system—arenas in which nurses are familiar and have demonstrated their value. Nurses at all levels are positioned to play key roles in a reformed and restructured care delivery system, such as:
Coordinating healthcare consumers’ transitions between healthcare delivery systems and settings (e.g., from hospital to rehabilitation to home)
Monitoring and managing healthcare consumers with chronic disease
Promoting wellness and providing preventive health care
Providing individualized care in nurse-managed health centers
Participating in the “medical home” (“healthcare home”) model for care management
Utilizing advanced practice registered nurses to the fullest extent of their scope of practice consistent with education and competencies.
The nursing shortage looms as the greatest challenge to nurses to fill their critical role in health care. The aging nursing workforce, coupled with aging baby boomers, has created an imminent crisis in which record demand is timed to occur as nurses retire (Curtin, 2007). As more students are recruited into nursing, schools struggle to increase capacity. Faculty shortages—related to aging faculty, length of time to complete graduate education, heavy workload, and low salaries—severely hamper attempts by nursing schools to expand. Concern over the worsening shortage has provided the impetus for a number of innovative efforts to increase nursing capacity, including strategic partnerships to align and leverage stakeholder resources, increasing faculty capacity through accelerated programs and joint positions, redesigning nursing education, and changing policy and regulation (Joynt & Kimball, 2008).
In the face of healthcare reform and the nursing shortage, IOM and the Robert Wood Johnson Foundation have established a major initiative with the intent of “reconceptualizing the role of nurses within the context of the entire workforce, the shortage, societal issues, and current and future technology” (RWJF & IOM, 2009). The value of registered nurses in patient safety and positive patient outcomes in hospital settings is well demonstrated (Kane, Shamilyan, Mueller, Duval, & Wilt, 2007).
As healthcare reform evolves, nurses may experience greater opportunities to function within their full scope of practice across various settings. A reformed healthcare system will provide much needed incentives and financial support for utilizing nurses in various roles and promoting a full scope of practice, and eliminate the current payment practices that create barriers to innovative and effective models of practice and care delivery.
Employers are correcting workplace problems in an attempt to retain nurses. Safe patient handling, shift and scheduling options, integration of technology supports into practice, and alternative roles in the healthcare setting have enabled nurses to remain in the workplace.
As the nurse of the future evolves, so must nursing education. Curricula must be designed to adequately prepare competent entry-level nurses. The nurse shortage and program capacity limits demand efficient educational processes. Online, virtual, simulated, and competency-based learning are attempts to expand opportunities to students and increase efficiency. However, design should be based on evidence more than tradition so that the nurse graduate is prepared to provide safe and competent care.
Nursing as a profession continues to face dilemmas in entry into practice, the autonomy of advanced practice, continued competence, multistate licensure, and the appropriate educational credentials for professional certification. Registered nurses have a professional responsibility to maintain competence in their area of practice. Employers who provide opportunities for professional development and continuing education promote a positive practice environment in which nurses can maintain and enhance skills and competencies.
Technology offers a better work environment for nurses when designed and implemented in a manner that supports nurses’ work. These work environments can include conventional locations—hospitals, clinics, and healthcare consumer homes—as well as virtual spaces such as online discussion groups, email, interactive video, and virtual interaction. Ideally, technology eliminates redundancy and duplication of documentation; reduces errors; eliminates interruptions for missing supplies, equipment, and medications; and eases access to data, thereby allowing the nurse more time with the patient (Pamela Cipriano, PhD, RN, FAAN, in IOM, 2009). The incorporation of technologies, however, is not without risk, and demands diligence by registered nurses to consider the impact on the scope of nursing practice and the ethical implications for healthcare consumers as well as the nurse.
The healthcare industry has been challenged to improve patient safety, patient and practitioner satisfaction, patient outcomes, and the profitability of the healthcare organization (Kennedy, 2003). In 1999 IOM described the nation’s healthcare system as fractured, prone to errors, and detrimental to safe patient care. IOM has identified six aims for improvement so that the healthcare system is: safe, effective, patient-centered, timely, efficient, and equitable (IOM, 2001).
Whatever the practice venue, in the next decade registered nurses will continue to partner with others to advance the nation’s health through many initiatives, such as Healthy People 2020. Such partnerships truly reflect the
definition of nursing and illustrate the essential features of contemporary nursing practice:
A caring relationship that facilitates health and healing
Attention to the range of human experiences and responses to health, disease, and illness in the physical and social environments
Integration of objective data with knowledge gained from an appreciation of the healthcare consumer’s or group’s subjective experience
Application of scientific knowledge to 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 (ANA, 2010)
Summary of the Scope of Nursing Practice
The dynamic nature of the healthcare practice environment and the growing body of nursing research provide both the impetus and the opportunity for nursing to ensure competent nursing practice in all settings for all healthcare consumers and to promote ongoing professional development that enhances the quality of nursing practice. Nursing: Scope and Standards of Practice, Second Edition, assists that process by delineating the professional scope and standards of practice and responsibilities of all professional registered nurses engaged in nursing practice, regardless of setting. As such, it can serve as a basis for:
Quality improvement systems
Healthcare reimbursement and financing methodologies
Development and evaluation of nursing service delivery systems and organizational structures
Position descriptions and performance appraisals
Agency policies, procedures, and protocols
Establishing the legal standard of care
To best serve the public’s health and the nursing profession, nursing must continue its efforts to establish the Standards of Professional Nursing Practice. Nursing also must examine how the Standards of Professional Nursing Practice can be disseminated and used most effectively to enhance and promote the quality of practice. In addition, the Standards of Professional Nursing Practice must be continually evaluated and revised as necessary.
The dynamic healthcare practice environment and the growing body of nursing research provide both the impetus and the opportunity for nursing to ensure competent nursing practice in all settings for all healthcare consumers and to promote ongoing professional development that enhances the quality of nursing practice.
Standards of Professional Nursing Practice
Significance of Standards
The Standards of Professional Nursing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. The standards published herein may be utilized as evidence of the standard of care, with the understanding that application of the standards is context dependent. The standards are subject to change with the dynamics of the nursing profession, as new patterns of professional practice are developed and accepted by the nursing profession and the public. In addition, specific conditions and clinical circumstances may also affect the application of the standards at a given time, e.g., during a natural disaster. The standards are subject to formal, periodic review and revision. (See page 87 for information of this review and revision process.)
The Standards of Professional Nursing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. The standards published herein:
May be utilized as evidence of the standard of care, with the understanding that application of the standards is context dependent
Are subject to change with the dynamics of the nursing profession, as new patterns of professional practice are developed and accepted by the nursing profession and the public, and
Are subject to formal, periodic review and revision.
The competencies that accompany each standard may be evidence of compliance with the corresponding standard. The list of competencies is not exhaustive for a given standard. Whether a particular standard or competency applies depends upon the circumstances.
Standards of Practice
Standard 1. Assessment
The registered nurse collects comprehensive data pertinent to the healthcare consumer’s health and/or the situation.
The registered nurse:
Collects comprehensive data including but not limited to physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic assessments in a systematic and ongoing process while honoring the uniqueness of the person.
Elicits the healthcare consumer’s values, preferences, expressed needs, and knowledge of the healthcare situation.
Involves the healthcare consumer, family, and other healthcare providers as appropriate, in holistic data collection.
Identifies barriers (e.g., psychosocial, literacy, financial, cultural) to effective communication and makes appropriate adaptations.
Recognizes the impact of personal attitudes, values, and beliefs.
Assesses family dynamics and impact on healthcare consumer health and wellness.
Prioritizes data collection based on the healthcare consumer’s immediate condition, or the anticipated needs of the healthcare consumer or situation.
Uses appropriate evidence-based assessment techniques, instruments, and tools.
Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances.
Applies ethical, legal, and privacy guidelines and policies to the collection, maintenance, use, and dissemination of data and information.
Recognizes the healthcare consumer as the authority on her or his own health by honoring their care preferences.
Documents relevant data in a retrievable format.
ADDITIONAL COMPETENCIES FOR THE GRADUATE-LEVEL PREPARED SPECIALTY NURSE AND THE APRN
The graduate-level prepared specialty nurse or the advanced practice registered nurse:
Initiates and interprets diagnostic tests and procedures relevant to the healthcare consumer’s current status.
Assesses the effect of interactions among individuals, family, community, and social systems on health and illness.
Standard 2. Diagnosis