American Nurses Association Silver Spring, Maryland 2015


American Nurses Association Silver Spring, Maryland 2015

3rd Edition

Scope and Standards of PracticeNursing

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The American Nurses Association (ANA) is a national professional association. This ANA publication, Nursing: Scope and Standards of Practice, Third Edition, reflects the thinking of the nursing profession on various issues and should be reviewed in conjunction with state board of nursing policies and practices. State law, rules, and regulations govern the practice of nursing, while Nursing: Scope and Standards of Practice, Third Edition, guides nurses in the application of their professional knowledge, skills, and responsibilities.

American Nurses Association 8515 Georgia Avenue, Suite 400 Silver Spring, MD 20910-3492 1-800-274-4ANA http://www.Nursingworld.org

Published by Nursesbooks.org The Publishing Program of ANA http://www.Nursesbooks.org

Copyright ©2015 American Nurses Association. All rights reserved. Reproduction or transmission in any form is not permitted without written permission of the American Nurses Association (ANA). This publication may not be translated without written permission of ANA. For inquiries, or to report unauthorized use, email copyright@ ana.org.

Cataloging-in-Publication Data on file with the Library of Congress

ISBN-13: 978-1-55810-619-2 SAN: 851-3481 07/2015

First printing: July 2015

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Contents Nursing: Scope and Standards of Practice, 3rd Ed. iii

Contents

Contributors vii

Overview of the Content xi Essential Documents of Professional Nursing xi Additional Content xi Audience for This Publication xii

Scope of Nursing Practice 1 Definition of Nursing 1 Professional Nursing’s Scope and Standards of Practice 1

Description of the Scope of Nursing Practice 2 Development and Function of the Standards of Professional Nursing Practice 3

Standards of Practice 4 Standards of Professional Performance 5 The Function of Competencies in Standards 6

Integrating the Art and Science of Nursing 6 The What and How of Nursing 7

Tenets Characteristic of Nursing Practice 7 The How of Nursing 9 The Art of Nursing 11 The Science of Nursing 13

When Nursing Occurs 16 Nursing Knowledge, Research, and Evidence-based Practice 16

The Where of Nursing Practice 19 Healthy Work Environments for Nursing Practice 21

Safe Patient Handling and Mobility (SPHM) 22 Fatigue in Nursing Practice 22 Workplace Violence and Incivility 22 Optimal Staffing 23 Supports for Healthy Work Environments 23 High-Performing Interprofessional Teams 27

Key Influences on the Quality and Environment of Nursing Practice 28

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iv Nursing: Scope and Standards of Practice, 3rd Ed. Contents

Societal, Cultural, and Ethical Dimensions Describe the Why and How of Nursing 31 Model of Professional Nursing Practice Regulation 33 The Code of Ethics for Nurses 36 Specialty Practice in Nursing 37

Professional Registered Nurses Today: The Who of Nursing 38 Statistical Snapshot 38 Licensure and Education of Registered Nurses 41 Advanced Practice Registered Nurse Roles 42 Professional Competence in Nursing Practice 43 Evaluating Competence 45

Professional Trends and Issues 45 Creating a Sustainable Nursing Workforce 46 Nursing Education 47 Technological Advances 48

Population Focus: Redefining Health and Well-being for the Millennial Generation 48

Baby Boomers: Health and Chronic Illness 48 Summary of the Scope of Nursing Practice 49

Standards of Professional Nursing Practice 51 Significance of Standards 51

Standards of Practice 53 Standard 1. Assessment 53 Standard 2. Diagnosis 55 Standard 3. Outcomes Identification 57 Standard 4. Planning 59 Standard 5. Implementation 61 Standard 5A. Coordination of Care 63 Standard 5B. Health Teaching and Health Promotion 65 Standard 6. Evaluation 66

Standards of Professional Performance 67 Standard 7. Ethics 67 Standard 8. Culturally Congruent Practice 69 Standard 9. Communication 71 Standard 10. Collaboration 73 Standard 11. Leadership 75 Standard 12. Education 76 Standard 13. Evidence-based Practice and Research 77 Standard 14. Quality of Practice 79 Standard 15. Professional Practice Evaluation 81 Standard 16. Resource Utilization 82 Standard 17. Environmental Health 84

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Contents Nursing: Scope and Standards of Practice, 3rd Ed. v

Glossary 85

References and Bibliography 91

Appendix A: Nursing: Scope and Standards of Practice, 2nd Edition (2010) 99

Appendix B: Nursing’s Social Policy Statement: The Essence of the Profession (2010) 175

Appendix C: ANA Position Statement: Professional Role Competence (2014) 213

Appendix D: The Development of Essential Nursing Documents and Professional Nursing 223

Appendix E: Selected Nurse Theorists 227

Appendix F: Culturally Congruent Practice Resources 229

Index 235

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Contributors Nursing: Scope and Standards of Practice, 3rd Ed. vii

Contributors

Nursing: Scope and Standards of Practice, Third Edition, is the product of exten- sive thought work by many registered nurses and a three-step review process. This document originated from the decisions garnered during a significant number of telephone conference calls and electronic mail communications of the diverse workgroup members and an intensive two-day in person week- end meeting. The first review process, a 30-day public comment period, fol- lowed. All workgroup members reviewed every comment, resulting in further workgroup refinements of the draft document. The official American Nurses Association (ANA) review process included evaluation by the Committee on Nursing Practice Standards and final review and approval by the ANA Board of Directors in June 2015. The list of endorsing organizations that completes this section reflects the broad acceptance of this resource within the profession.

Nursing Scope and Standards Workgroup, 2014–2015

Elizabeth Thomas, MEd, RN, NCSN, FNASN, Chairperson

Chad Allen, RN

Sheri-Lynne Almeida, DrPH, MSN, MED, RN, CEN, FAEN

Carolyn Baird, DNP, MBA, RN-BC, CARN-AP, CCDPD, FIAAN

Nancy Barr, MSN, RN

Patricia Bartzak, DNP, RN, CMSRN

Mavis Bechtle, MSN, RN

Jennifer Bellot, PhD, MHSE, RN, CNE

Tom Blodgett, PhD, MSN, GCNS, RN-BC

Patricia Bowe, MS, BSN, RN

Katreena Collette-Merrill, PhD, RN

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viii Nursing: Scope and Standards of Practice, 3rd Ed. Contributors

Kahlil Demonbreun, DNP, RNC-OB, WHNP-BC, ANP-BC

Sheila Eason, MS, BSN, RN, CNOR

Tim Fish, DNP, MBA, RN, CENP

Matthew French-Bravo, MSN, RN

Heather Healy, MS, APRN, FNP-BC, NEA-BC

Susan Howard, MSN, RN-BC

Brenda Hutchins, DNP, ANP-BC, GNP-BC

Lorinda Inman, MSN, RN, FRE

Donna Konradi, PhD, RN, CNE

Mary Ann Lavin, ScD, APRN, ANP-BC, FNI, FAAN

Carla Mariano, EdD, RN, AHN-BC, FAAIM

Lucy Marion, PhD, RN, FAANP, FAAN

Deborah Maust Martin, DNP, MBA, RN, NE-BC, FACHE

Cindy McCullough, MSN, CMSRN, AGCNS-BC

Kris A. McLoughlin, DNP; APRN; PMH-CNS, BC; CADC-II, FAAN

Joyce Morris, MSN, RN-BC

Sandra J. Fulton Picot, PhD, RN, CLNC, FGSA, FAAN

Deborah Poling, PhD, RN, FNP-BC, CNE

Lori L. Profata, DNP, RN, NE-BC

Karen Rea-Williams, MS, FNP

ShyRhonda Roy, MSN, RN

Debbie Ruiz, RN

Kathryn Schroeter, PhD, RN, CNE, CNOR

Melida Shepard, RN, BSN, CPHQ

Suzanne Sikes-Thurman, BA, BSN, RN

Janice Smolowitz, EdD, DNP, RN, ANP-BC

Lynn Tomascik, MSN, RN

Linda Wagner, MA, RN, NE-BC

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Contributors Nursing: Scope and Standards of Practice, 3rd Ed. ix

Acknowledgment of Special Contribution

Marilyn (Marty) Douglas, PhD, RN, FAAN

ANA Committee on Nursing Practice Standards

Richard Henker, PhD, RN, CRNA, FAAN: co- chair 03/2014–12/2015

Tresha (Terry) L. Lucas, MSN, RN: co- chair 07/2011–12/2014

Danette Culver, MSN, APRN, ACNS-BC, CCRN

Deborah Finnell, DNS, PMHNP-BC, CARN-AP, FAAN

Renee Gecsedi, MS, RN

Deedra Harrington, DNP, MSN, APRN, ACNP-BC

Maria Jurlano, MS, BSN, RN, NEA-BC, CCRN

Carla A. B. Lee, PhD, APRN-BC, CNAA, FAAN, FIBA

Verna Sitzer, PhD, RN, CNS

ANA Staff, 2014-2015

Carol J. Bickford, PhD, RN-BC, CPHIMS, FAAN – Content editor

Mary Jo Assi, DNP, RN, FNP-BC, NEA-BC

Maureen E. Cones, Esq. – Legal Counsel

Eric Wurzbacher, BA – Project editor

Yvonne Humes, MSA – Project assistant

About the American Nurses Association The American Nurses Association (ANA) is the only full-service professional organization representing the interests of the nation’s 3.4 million registered nurses through its constituent member nurses associations and its organiza- tional affiliates. ANA advances the nursing profession by fostering high stan- dards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on healthcare issues affecting nurses and the public.

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x Nursing: Scope and Standards of Practice, 3rd Ed. Contributors

About Nursesbooks.org, The Publishing Program of ANA Nursesbooks.org publishes books on ANA core issues and programs, includ- ing ethics, leadership, quality, specialty practice, advanced practice, and the profession’s enduring legacy. Best known for the Essential documents of the profession on nursing ethics, scope and standards of practice, and social policy, Nursesbooks.org is the publisher for the professional, career-oriented nurse, reaching and serving nurse educators, administrators, managers, and research- ers as well as staff nurses in the course of their professional development.

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Overview of the Content Nursing: Scope and Standards of Practice, 3rd Ed. xi

Overview of the Content

Essential Documents of Professional Nursing Registered nurses practicing in the United States have two contemporary pro- fessional resources that inform their thinking and decision-making and guide their practice. First, the Code of Ethics for Nurses with Interpretive Statements (American Nurses Association, 2015) lists the nine succinct provisions and accompanying interpretive statements that establish the ethical framework for registered nurses’ practice across all roles, levels, and settings. Secondly, the 2015 Nursing: Scope and Standards of Practice, Third Edition, outlines the expectations of professional nursing practice. The scope of practice statement presents the framework and context of nursing practice and accompanies the standards of professional nursing practice and their associated competencies that identify the evidence of the standard of care.

Additional Content For a better appreciation of the history, content, and context related to Nursing: Scope and Standards of Practice, Third Edition, readers will find the additional content of the six appendices useful:

Appendix A. Nursing: Scope and Standards of Practice, Second Edition (2010)

Appendix B. Nursing’s Social Policy Statement: The Essence of the Profession (2010)

Appendix C. ANA Position Statement : Professional Role Competence (2014)

Appendix D. The Development of Essential Nursing Documents and Professional Nursing

Appendix E. List of Selected Nurse Theorists

Appendix F. Culturally Congruent Practice Resources

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xii Nursing: Scope and Standards of Practice, 3rd Ed. Overview of the Content

Audience for This Publication Registered nurses in every clinical and functional role and setting constitute the primary audience of this professional resource. Students, interprofessional colleagues, agencies, and organizations also will find this an invaluable refer- ence. Legislators, regulators, legal counsel, and the judiciary will also want to examine this content. In addition, the individuals, families, groups, communi- ties, and populations using nursing and healthcare services can use this docu- ment to better understand what constitutes the profession of nursing and how registered nurses and advanced practice registered nurses lead within today’s healthcare environment.

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Scope of Nursing Practice Nursing: Scope and Standards of Practice, 3rd Ed. 1

Scope of Nursing Practice

Definition of Nursing The following contemporary definition of nursing has been slightly modified from that published in the 2003 Nursing’s Social Policy Statement, Second Edition, and included in the 2004 and 2010 editions of Nursing: Scope and Standards of Practice, with the inclusion of “facilitation of healing” and “groups”:

Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, allevia- tion of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations.

This definition serves as the foundation for the following expanded descrip- tions of the Scope of Nursing Practice and the Standards of Professional Nursing Practice.

Professional Nursing’s Scope and Standards of Practice A professional organization has a responsibility to its members and to the public it serves to develop the scope and standards of practice for its profes- sion. The American Nurses Association (ANA), the professional organization for all registered nurses, has long assumed the responsibility for developing and maintaining the scope of practice statement and standards that apply to the practice of all professional nurses and also serve as a template for evalua- tion of nursing specialty practice. Both the scope and standards do, however, belong to the profession and thus require broad input into their development and revision. Nursing: Scope and Standards of Practice, Third Edition describes a competent level of nursing practice and professional performance common to all registered nurses.

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2 Nursing: Scope and Standards of Practice, 3rd Ed. Scope of Nursing Practice

Description of the Scope of Nursing Practice

The Scope of Nursing Practice 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 definition of nursing pro- vides a succinct characterization of the “what” of nursing. Registered nurses and advanced practice registered nurses comprise the “who” constituency and have been educated, titled, and maintain active licensure to practice nursing. Nursing occurs “when”ever there is a need for nursing knowledge, wisdom, caring, leadership, practice, or education, anytime, anywhere. Nursing occurs in any environment “where” there is a healthcare consumer in need of care, information, or advocacy. The “how” of nursing practice is defined as the ways, means, methods, and manners that nurses use to practice professionally. The “why” is characterized as nursing’s response to the changing needs of society to achieve positive healthcare consumer outcomes in keeping with nursing’s social contract with an obligation to society. The depth and breadth in which individual registered nurses and advanced practice registered nurses engage in the total scope of nursing practice is dependent on their education, experience, role, and the population served.

These definitions are provided to promote clarity and understanding for all readers:

Healthcare consumers are the patients, persons, clients, families, groups, com- munities, or populations who are the focus of attention and to whom the regis- tered nurse is providing services as sanctioned by the state regulatory bodies. This more global term is intended to reflect a proactive focus on health and wellness care, rather than a reactive perspective to disease and illness.

Registered nurses (RNs) are individuals who are educationally prepared and licensed by a state, commonwealth, territory, government, or regulatory body to practice as a registered nurse. “Nurse” and “professional nurse” are syn- onyms for a registered nurse in this document.

Graduate-level prepared registered nurses are registered nurses prepared at the master’s or doctoral educational level; have advanced knowledge, skills, abil- ities, and judgment; function in an advanced level as designated by elements of the nurse’s position; and are not required to have additional regulatory oversight.

Advanced practice registered nurses (APRNs) are registered nurses:

Who have completed an accredited graduate-level education pro- gram preparing the nurse for one of the four recognized APRN roles [certified registered nurse anesthetist (CRNA), certified nurse

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Scope of Nursing Practice Nursing: Scope and Standards of Practice, 3rd Ed. 3

midwife (CNM), clinical nurse specialist (CNS), or certified nurse practitioner (CNP)];

Who have passed a national certification examination that measures APRN-, role-, and population-focused competencies and maintain continued competence as evidenced by recertification in the role and population through the national certification program;

Who have acquired advanced clinical knowledge and skills prepar- ing the nurse to provide direct care to patients, as well as a compo- nent of indirect care; however, the defining factor for all APRNs is that a significant component of the education and practice focuses on direct care of individuals;

Whose practices build on the competencies of registered nurses (RNs) by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and inter- ventions, and greater role autonomy;

Who are educationally prepared to assume responsibility and accountability for health promotion and/or maintenance as well as the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and non-pharmacologic interventions;

Who have clinical experience of sufficient depth and breadth to reflect the intended license; and

Who have obtained a license to practice as an APRN in one of the four APRN roles: certified registered nurse anesthetist (CRNA), certi- fied nurse midwife (CNM), clinical nurse specialist (CNS), or certified nurse practitioner (CNP) (APRN Joint Dialogue Group, 2008).

Development and Function of the Standards of Professional Nursing Practice

The Scope of Practice Statement is accompanied by the Standards of Professional Nursing Practice. The standards 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 applica- tion 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 or epidemic. As with the scope of practice statement, the standards are subject to formal, periodic review, and revision.

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4 Nursing: Scope and Standards of Practice, 3rd Ed. Scope of Nursing Practice

The Standards of Professional Nursing Practice consist 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, out- comes 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 pertinent data and information relative to the healthcare consumer’s health or the situation.

Standard 2. Diagnosis

The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and 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 to attain expected, measurable 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.

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Scope of Nursing Practice Nursing: Scope and Standards of Practice, 3rd Ed. 5

Standard 6. Evaluation

The registered nurse evaluates progress toward attainment of goals and 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, cultur- ally congruent practice, communication, collaboration, leadership, education, evidence-based practice and research, quality of practice, 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. Culturally Congruent Practice

The registered nurse practices in a manner that is congruent with cultural diversity and inclusion principles.

Standard 9. Communication

The registered nurse communicates effectively in all areas of practice.

Standard 10. Collaboration

The registered nurse collaborates with healthcare consumer and other key stakeholders in the conduct of nursing practice.

Standard 11. Leadership

The registered nurse leads within the professional practice setting and the profession.

Standard 12. Education

The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking.

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6 Nursing: Scope and Standards of Practice, 3rd Ed. Scope of Nursing Practice

Standard 13. Evidence-based Practice and Research

The registered nurse integrates evidence and research findings into practice.

Standard 14. Quality of Practice

The registered nurse contributes to quality nursing practice.

Standard 15. Professional Practice Evaluation

The registered nurse evaluates one’s own and others’ nursing practice.

Standard 16. Resource Utilization

The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and fiscally responsible.

Standard 17. Environmental Health

The registered nurse practices in an environmentally safe and healthy manner.

The Function of Competencies in Standards

The competencies that accompany each standard may be evidence of demon- strated compliance with the corresponding standard. The list of competen- cies is not exhaustive. Whether a particular standard or competency applies depends upon the circumstances. For example, a nurse providing treatment to an unconscious, critical healthcare consumer who presented to the hospital by ambulance without family has a duty to collect comprehensive data pertinent to the healthcare consumer’s health (Standard 1. Assessment). However, under the attendant circumstances, that nurse may not be expected “to assess family dynamics and impact on the healthcare consumer’s health and wellness” (one of Starndard 1’s competencies). In the same instance, Standard 5B. Health Teaching and Health Promotion might not apply at all.

Integrating the Art and Science of Nursing Nursing is a learned profession built on a core body of knowledge that reflects its dual components of art and science. Nursing requires judgment and skill based on principles of the biological, physical, behavioral, and social sciences. Registered nurses employ critical thinking to integrate objective data with knowledge gained from an assessment of the subjective experiences of health- care consumers. Registered nurses use critical thinking to apply the best avail- able evidence and research data to diagnosis and treatment decisions. Nurses

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Scope of Nursing Practice Nursing: Scope and Standards of Practice, 3rd Ed. 7

continually evaluate quality and effectiveness of nursing practice and seek to optimize outcomes.

Nursing promotes the delivery of holistic consumer-centered care and opti- mal health outcomes throughout the lifespan and across the health–illness continuum within an environmental context that encompasses culture, ethics, law, politics, economics, access to healthcare resources, and competing priori- ties. Similarly, nursing promotes the health of communities by using advocacy for social and environmental justice, community engagement, and access to high-quality and equitable health care to maximize population health outcomes and minimize health disparities. Nursing advocates for the well-being, comfort, dignity, and humanity of all individuals, families, groups, communities, and populations. Nursing focuses on healthcare consumer and interprofessional collaboration, sharing of knowledge, scientific discovery, and social welfare.

The What and How of Nursing What Is Nursing?

What is nursing? Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations. This succinct but very powerful definition statement (see p. 11) reflects the evolution of the profession. The integration of the art and science of nursing is described in the following detailed scope and standards of practice content.

Nursing is a learned profession built on a core body of knowledge that reflects its dual components of art and science. Nursing requires judgment and skill based on principles of the biological, physical, behavioral, and social sciences.

Tenets Characteristic of Nursing Practice

The conduct of nursing practice in all settings also can be characterized by the following tenets that are reflected in language that threads throughout the scope of practice statement and standards of practice and professional performance.

1. Caring and health are 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, 2008, 2012). “Caring is a conscious judgment that manifests itself in concrete acts, interpersonally, verbally, and nonverbally”

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8 Nursing: Scope and Standards of Practice, 3rd Ed. Scope of Nursing Practice

(Gallagher-Lepak & Kubsch, 2009, p. 171). While caring for indi- viduals, families, groups, and populations is the key focus of nursing, the nurse additionally promotes self-care as well as care of the envi- ronment and society (Hagerty, Lynch-Sauer, Patusky, & Bouwseman, 1993; ANA, 2015).

2. Nursing practice is individualized.

Nursing practice respects diversity and focuses on identifying and meeting the unique needs of the healthcare consumer or situation. Healthcare consumer is defined to be the patient, person, client, fam- ily, 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.

3. Registered nurses use the nursing process to plan and provide individu- alized care for healthcare consumers.

The nursing process is cyclical and dynamic, interpersonal and col- laborative, and universally applicable. 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 that has been individ- ualized to achieve the best outcomes. Nursing actions are intended to produce beneficial effects, contribute to quality outcomes, and above all, “do no harm.” Nurses evaluate the effectiveness of care in relation to identified outcomes and use evidence-based practice to improve care. Critical thinking underlies each step of the nursing process, problem-solving, and decision-making.

4. Nurses coordinate care by establishing partnerships.

The registered nurse establishes partnerships with persons, fami- lies, groups, support systems, and other providers, utilizing effective in-person and electronic communications, to reach a shared goal of delivering safe, quality health care to address the health needs of the healthcare consumer and the public. The registered nurse is respon- sible and accountable for communicating and advocating for the planning and care coordination focused on the healthcare consumer, families, and support systems (ANA, 2013a). Collaborative interpro- fessional team planning is based on recognition of each individual profession’s value and contributions, mutual trust, respect, open dis- cussion, and shared decision-making.

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Scope of Nursing Practice Nursing: Scope and Standards of Practice, 3rd Ed. 9

5. A strong link exists between the professional work environment and the registered nurse’s ability to provide quality health care and achieve opti- mal outcomes.

Professional nurses have an ethical obligation to maintain and improve healthcare practice environments conducive to the pro- vision of quality health care (ANA, 2015). Extensive studies have demonstrated the relationship between effective nursing practice and the presence of a healthy work environment. Mounting evi- dence demonstrates that negative, demoralizing, and unsafe condi- tions in the workplace (unhealthy work environments) contribute to errors, ineffective delivery of care, workplace conflict and stress, and moral distress.

The How of Nursing

The “how” of nursing practice is defined as the ways, means, methods, processes, and manner by which the registered nurse practices professionally. The ways in which registered nurses practice reflect integration of the five core practice competencies of all healthcare professionals: healthcare consumer-centered practice, evidence-based practice, interprofessional collaboration, use of infor- matics, and continuous quality improvement (Institute of Medicine, 2003). Registered nurses recognize that using a holistic approach prevents omission of relevant data when implementing the nursing process. When incorporat- ing a healthcare consumer-centered approach, the registered nurse collaborates with and treats all healthcare consumers with the utmost respect. The reg- istered nurse demonstrates culturally congruent practice, always advocating that healthcare consumers have sufficient information and questions answered, enabling them to exercise their autonomy to make the final decisions regarding their preferred care.

To achieve the best healthcare consumer outcomes, the “how” requires the registered nurse to employ evidence-based practice as a means to incorporate the best available evidence, healthcare consumer preferences, provider exper- tise, and contextual resources in which nursing is delivered. Closely linked to the best healthcare consumer outcomes is the need for effective interprofes- sional collaboration. Thus, an essential component of the “how” of registered nursing is care coordination (ANA, 2013a), requiring effective communica- tions by all stakeholders.

Additionally, the “how” of registered nursing practice encompasses methods such as communicating predictably and comprehensively using approaches such as informatics, electronic health records, and established processes to pre- vent errors. Methods can include situation, background, assessment, recommen- dation (SBAR) (The Joint Commission Enterprise, 2012) and TeamSTEPPSR

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10 Nursing: Scope and Standards of Practice, 3rd Ed. Scope of Nursing Practice

as evidence-based methods of building teamwork and communication skills (Department of Defense 2014; Agency for Healthcare Research and Quality, n.d.).

Critical to the practice of professional nursing is ethical conduct of research to generate new knowledge and translate that knowledge to practice using theory-driven approaches (Estabrooks, Thompson, Lovely, & Hofmeyer, 2006). Finally, the “how” of registered nursing practice reflects the manner in which the registered nurse practices according to the Code of Ethics for Nurses with Interpretive Statements, standards for professional nursing practice, institutional review boards’ protocols, and directives of other governing and regulatory bodies that guide the conduct of professional nursing practice.

These activities reflect nursing’s long-standing commitment to its responsibil- ities to the society out of which it grew and continues to serve. Such a profes- sional relationship and associated expectations and contributions toward the evolution of a health-oriented system of care were first formally articulated in the 1980 Nursing: A Social Policy Statement. Later editions of the social policy statement in 1995, 2003, and 2010 confirmed the importance of nurse– healthcare consumer partnerships; healthcare consumers’ decision-making, accountability, and responsibility of choice; and the necessary focus on health- care consumer-centered care and outcomes.

Nursing’s Social Policy Statement: The Essence of the Profession identifies the following statements that undergird professional nursing’s social contract with society (ANA, 2010b, p. 6):

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 pre- clude 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.

Consult Appendix B, Nursing’s Social Policy Statement for discussion of other content important to understanding the societal context related to the decision-making and conduct of professional nursing practice.

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Scope of Nursing Practice Nursing: Scope and Standards of Practice, 3rd Ed. 11

The Art of Nursing

The art of nursing is based on caring and respect for human dignity. A com- passionate approach to patient care carries a mandate to provide care com- petently. Such competent care is provided and accomplished through both independent practice and partnerships. Collaboration may be with individuals seeking support or assistance with their healthcare needs, interprofessional colleagues, and other stakeholders.

The art of nursing embraces spirituality, healing, empathy, mutual respect, and compassion. These intangible aspects promote health. Nursing embraces healing. Healing is fostered by helping, listening, mentoring, coaching, teach- ing, exploring, being present, supporting, touching, intuition, service, cultural competence, tolerance, acceptance, nurturing, mutually creating, and conflict resolution.

Nursing focuses on the protection, promotion, and optimization of health and quality of life; prevention or resolution of disease, illness, or disability; facilitation of healing, alleviation of suffering; and transition to a dignified and peaceful death. Nursing needs 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 promo- tive, supportive, and restorative in nature.

Care and Caring in Nursing Practice

The act of caring is foundational to the practice of nursing: “A great truth, the act of caring is the first step in the power to heal” (Moffitt, 2004, p. 23). Watson (2012), in her Human Caring Science Theory, emphasizes the personal relation- ship between patient and nurse; highlights the role of the nurse in defining the patient as a unique human being to be valued, respected, nurtured, under- stood, assisted; and stresses the importance of the connections between the nurse and patient. Human care and caring is viewed as the moral ideal of nurs- ing consisting of human-to-human attempts to protect, enhance, and preserve humanity and human dignity, integrity, and wholeness by assisting a person to find meaning in illness, suffering, pain, and existence. Human caring helps another gain self-knowledge, self-control, self-caring, and self-healing so that a sense of inner harmony is restored regardless of the external circumstances.

Human caring is not just an emotion, concern, attitude, or benevolent desire. It involves values, knowledge, caring actions, acceptance of consequences, a will, and a commitment to care. Human caring is related to intersubjec- tive human responses to health-illness-healing conditions; a knowledge of health-illness, environmental-personal relations, and the nurse caring process; and self-knowledge in relation to both strengths and limitations. Human caring

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12 Nursing: Scope and Standards of Practice, 3rd Ed. Scope of Nursing Practice

follows a process consisting of antecedents, attributes, and outcomes of caring, which go on to affect future encounters of caring.

This process includes the care recipient and the nurse, both of whom are required in a human caring relationship. The nurse must possess competence, professional maturity, interpersonal sensitivity, a moral foundation that sup- ports caring actions, and access to a setting that is conducive to caring, while the care recipient must possess a need for and openness to caring. When combined, these antecedents can produce an intimate relationship between the care recipient and the nurse in which caring can occur to improve the physical and mental well-being of the healthcare consumer and feelings of satisfaction and renewal for the nurse.

In a caring relationship, the nurse utilizes well-honed assessment skills based on insight garnered through interpersonal sensitivity to accurately identify nuances and help find meaning in the care recipient’s situation. Interventions that reflect a caring consciousness may require creativity and daring, but can also be demonstrated in simple gestures of interpersonal connection, such as attentive listening, touching, and making eye contact, and sensitivity to cultural meanings associated with caring behaviors (Finfgeld-Connett, 2007).

Caring is

Grounded in ethics, beginning with respect for the autonomy of the care recipient,

Grounded, as a science, in nursing, but is not limited to nursing,

An attribute that may be taught, modeled, learned, mastered,

Capable of being measured and analyzed scientifically,

The subject of study within caring science institutes/academies worldwide, and

Central to relationships that lead to effective healing, cure, and/or actualization of human potential.

The caring embraced by nursing and described here does not compete with nor is it diminished by technological advances, individual or group wealth or its absence, professional or socioeconomic status or prestige or its lack, or any other parameter that attempts to categorize the place of the person in society. The act of caring, as well as the theory and science of caring, is all-inclusive:

The nursing profession has an ethical and social responsibility to both individuals and society to sustain human caring in instances where it is threatened, and to be the guardian of human caring,

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Scope of Nursing Practice Nursing: Scope and Standards of Practice, 3rd Ed. 13

individually and collectively, serving as the vanguard of society’s human caring needs now and in the future. If nursing does not fulfill its societal mandate for sustaining human caring, preserving human dignity and humanness in self, systems, and society, it will not be carrying out its covenant to humankind and its reason for existence as a profession. (Watson, 2012, p. 42)

Cultural Components of Care

Leininger (1988) considered care for people from a broad range of cultures and contributed to the unique body of nursing knowledge by translating and integrating transcultural precepts from the field of anthropology into nurs- ing science. She provided nursing with a global context, specifically exposing nursing to worldly cultures and learned behaviors, beyond those encountered within a dominant culture. Transcultural literacy has deepened nursing’s holis- tic approach by providing a framework to better understand and provide care to culturally diverse individuals, groups, and communities.

The Science of Nursing

Nurses as scientists rely on qualitative and quantitative evidence to guide pol- icies and practices, but also as a way of identifying the nurses’ impact on the health outcomes of healthcare consumers. When describing how nurses complete professional thinking and activities, the nursing process emerges as a commonly used analytical critical thinking framework.

The nursing process is conceptualized as a cyclic, iterative, and dynamic process including assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. The nursing process supports evidence-based practice and relies heavily on the bidirectional feedback loops between com- ponents, as illustrated in Figure 1. The hexagon delineates the six steps of the nursing process beginning with assessment at the 12 o’clock position, followed clockwise with diagnosis, outcomes identification, planning, implementation, and evaluation. Note the iterative actions reflected with bidirectional arrows.

The Standards of Practice included in the first ring 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 surrounding Standards of Professional Performance identified in the out- ermost ring reflect how the professional nurse adheres to the Standards of Practice, completes the nursing process, and addresses other nursing practice issues and concerns.

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14 Nursing: Scope and Standards of Practice, 3rd Ed. Scope of Nursing Practice

FIGURE 1. The Nursing Process and the Standards of Professional Nusing Practice

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Scope of Nursing Practice Nursing: Scope and Standards of Practice, 3rd Ed. 15

The Standards of Practice

These standards describe a competent level of nursing practice demonstrated by the critical thinking model known as the nursing process; its six compo- nents correspond to these standards.

Standard Nursing Process Component Standard 1 Assessment Standard 2 Diagnosis Standard 3 Outcomes Identification Standard 4 Planning Standard 5 Implementation Standard 6 Evaluation

The Standards of Professional Performance

These standards describe a competent level of behavior in the professional role appropriate to their education and position.

Standard Professional Performance Standard 7 Ethics Standard 8 Culturally Congruent Practice Standard 9 Communication Standard 10 Collaboration Standard 11 Leadership Standard 12 Education Standard 13 Evidence-based Practice and Research Standard 14 Quality of Practice Standard 15 Professional Practice Evaluation Standard 16 Resource Utilization Standard 17 Environmental Health

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16 Nursing: Scope and Standards of Practice, 3rd Ed. Scope of Nursing Practice

When Nursing Occurs

Nursing occurs whenever there is a need for nursing knowledge, wisdom, caring, leadership, practice, or education. The term “whenever” encompasses anytime, anywhere, with anyone.

Timing relates less to a point in time as measured by a clock and more to the continuum of life events that relate to past, present, and future health and responses to illness/injury. The time for nursing is: when there is need for support, guidance, healing, advocacy, nursing expertise; during life transitions, challenges, developmental and situational crises, and health maintenance; and before and during social and healthcare change. The timing of nursing refers less to when any one observation or action is made, but more to the grasping of the meaning of healthcare actions performed and outcomes attained and acting upon that meaning in a manner consistent with one’s knowledge, education, and scope and standards of practice.

Nursing happens when there are retrospective circumstances requiring anal- ysis and action, including root cause, risk factors, lifestyle, familial, cultural, genetic, environmental predispositions, or loss. It happens in the present when working with healthcare consumers within the context of their meaning applied to the diagnosis, illness, issue, problem, situation, or challenge being faced. Nursing happens when, through active and informed vigilance, nurses assess, diagnose risks, and intervene to prevent complications. Nursing happens pro- spectively when dealing with anticipatory guidance, health promotion, disease prevention, well-being, wellness, and transition.

When nursing is practiced, it is holistic and the nurse:

Partners with the individual/family/group/community/population;

Considers norms and values, health and illness perspectives and practices, customs, behaviors, and beliefs of the healthcare con- sumer; and

Arrives at healthcare decisions that are contextualized by how the individual/family/group/community/population perceives health, the nature of the body, and its relationship to mind, emotion, energy, spirit, or environment.

Nursing Knowledge, Research, and Evidence-based Practice

Contemporary nursing practice has its historical roots in the poorhouses, the battlefields, and the industrial revolutions in 19th-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

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Scope of Nursing Practice Nursing: Scope and Standards of Practice, 3rd Ed. 17

Nightingale provided a foundation for nursing and the basis for autonomous nursing practice as distinct from medicine. Nightingale is credited with iden- tifying the importance of collecting empirical evidence, the underpinning of nursing’s current emphasis on evidence-based practice:

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