Nursing as a profession
Florence Nightingale believed that a nurse’s goal should be “to put the patient in the best condition for nature to act upon him.” Definitions of nursing have changed over time, but nursing has retained a common focus: providing humanistic and holistic care to each patient.
Focus, focus
The American Nurses Association’s (ANA) definition of nursing shares this focus: “The practice of nursing by a registered nurse is defined as the process of diagnosing human responses to actual or potential health problems; providing supportive and restorative care, health counseling and teaching, case finding and referral; collaborating the implementation of the total health care regimen; and executing the medical regimen under the direction of a licensed physician or dentist.”
Not just a job
Most people use the term“nursing professionals” to describe a group of people who practice nursing. However, not everyone agrees that nursing has the full autonomy that it needs to distinguish itself as a profession rather than an occupation.
We’ve got the power
Nursing already has achieved some degree of autonomy. It exercises control over its education and practice. It has achieved legal recognition through licensure. Every state and Canadian province now has a nurse practice act, which requires nurses to pass state board examinations in order to practice and regulates the scope of their practice. Nursing also has a code of ethics, which is regularly updated to reflect current ethical issues.
Independence is key
The key to professional nursing autonomy, however, is to function independently of any other profession or external force. For many nurses, this remains a goal to be achieved. As employees of large, sometimes inflexible organizations, nurses seldomenjoy full latitude in deciding on patient care within the defined scope of nursing practice. However, by striving for individual excellence, each nurse can help this emerging profession become a full-fledged profession.
Educational preparation
The ANAhas identified two categories of nursing practice professional and associate and established educational requirements for each. According to the ANA’s guidelines, the minimumrequirement for beginning professional nurses is a baccalaureate degree in nursing (BSN), whereas the minimumrequirement for beginning associate nurses is an associate’s degree in nursing (ADN).
Options abound
Besides pursuing a BSN at a 4-year college or university or an ADN at a junior or community college, today’s undergraduate student nurses have a third option: hospitaloperated diploma programs. However, regardless of which option she chooses, a graduate of any of these three programs is eligible to sit for the same registered nurse
Graduate level
After the nurse receives her baccalaureate degree, she may choose to advance her education at the graduate level. She can choose froma number of graduate fields, including nursing. She can choose a Master of Arts (MA) in nursing, Master in Nursing (MN), or Master of Science in Nursing (MSN). Amaster’s degree qualifies a nurse to serve as a nurse educator, clinical nurse specialist, nursing administrator, or nurse practitioner.
Is there a doctor in the house?
Doctoral education in nursing is expanding. Most doctoral programs in nursing lead to a Doctor of Philosophy (PhD) degree or a doctorate in nursing practice (DNP). Anurse with a doctorate might assume a leadership position in a practice setting or as an educator of beginning nurses and those seeking advanced clinical and educational preparation, including research in nursing.
Practice guidelines
The way you practice your profession of nursing should be guided by two sets of care documents: standards of nursing care and nurse practice acts. The standards of nursing care are administered by the ANA, and the nurse practice acts are administered by individual states or provinces.
Standards of nursing care
Standards of care set minimumcriteria for your proficiency on the job, enabling you and others to judge the quality of care you and your nursing colleagues provide. They help to ensure high-quality care and, in the legal arena, they serve as criteria to help determine whether adequate care was provided to a patient. States may refer to standards in their nurse practice acts. Unless included in a nurse practice act, professional standards aren’t laws; they’re guidelines for sound nursing practice.
Pie in the sky?
Some nurses regard standards of nursing care as pie-in-the-sky ideals that have little bearing on the reality of working life. This opinion is a dangerous misconception. You’re expected to meet standards of nursing care for every nursing task you perform. The ANAstandards include two lists:
• standards of professional performance, which include guidelines for quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, resource utilization, and leadership
• standards of practice, which outline professional responsibilities in assessment, diagnosis, outcome identification, planning, implementation, and evaluation. (See ANA standards of nursing practice, pages 8 to 12.)
ANAstandards of nursing practice
The standards below are adapted fromstandards of nursing practice published by the American Nurses Association (ANA). The ANAdeveloped the standards (last revised in 2010) to provide registered nurses with guidelines for determining quality nursing care.
The courts as well as hospitals, nurses, and patients may refer to these standards. The standards of nursing practice are divided into the standards of practice, which define care provided to patients, and the standards of professional performance, which explain the level of behavior expected of the nurse in a professional role.
Each standard below is followed by measurement criteria that give key indicators of competent practice for that standard. This adaptation of the standards doesn’t present the standards that are specific only to advanced practice nurses.
STANDARDS OFPRACTICE
Standard
1: Assessment
The nurse collects patient health data.
Measurement criteria
1. Data collection is systematic and ongoing.
2. Data collection involves the patient, partners, and health care providers when appropriate.
3. Priority of data collection activities is determined by the patient’s immediate condition or needs.
4. Pertinent data are collected using appropriate evidence-based assessment techniques and instruments.
5. Analytical models and problemsolving tools are used.
6. Patterns and variances are identified by synthesizing relevant data and knowledge.
7. Relevant data are documented in a retrievable form.
Standard 2: Diagnosis
The nurse analyzes the assessment data in determining the diagnosis. Measurement criteria
1. Diagnoses are derived fromthe assessment data.
2. Diagnoses are validated with the patient, partners, and health care providers when possible.
3. Diagnoses are documented in a manner that facilitates the determination of the expected outcomes and care plan.
Standard 3: Outcomes identification
The nurse identifies expected outcomes individualized to the patient. Measurement criteria
1. Identification of outcomes involves the patient, family, and health care providers when possible and appropriate.
2. Outcomes are culturally appropriate and are derived fromthe diagnoses.
3. Outcomes are formulated taking into account any associated risks, benefits, costs, current scientific evidence, and clinical expertise.
4. Outcomes are defined in terms of the patient, the patient’s values, ethical considerations, environment, or situation along with any associated risks, benefits, costs, and current scientific evidence.
5. Outcomes include a time estimate for attainment.
6. Outcomes provide direction for continuity of care.
7. Outcomes are modified based on the patient’s status.
8. Outcomes are documented as measurable goals.
Standard 4: Planning
The nurse develops a care plan that prescribes interventions to attain expected outcomes. Measurement criteria
1. The plan is individualized to the patient’s condition or needs.
2. The plan is developed with the patient, partners, and health care providers.
3. The plan includes strategies that address each of the diagnoses.
4. The plan provides for continuity of care.
5. The plan includes a pathway or timeline.
6. Priorities for care are established with the patient, family, and others when appropriate.
7. The plan provides directions to other health care providers.
8. The plan reflects current statutes, rules and regulations, and standards.
9. The plan integrates current trends and research.
10. The economic impact of the plan is considered.
11. The plan is documented using standardized language and terminology.
Standard 5: Implementation
The nurse implements the plan.
Measurement criteria
1. Interventions are implemented in a safe and timely manner.
2. Interventions and any modifications to the plan are documented.
3. Interventions are evidence-based and specific to the diagnosis.
4. Interventions include community resources and systems.
5. Implementation includes collaboration with other health care providers.
Standard 5a: Coordination of care
The nurse coordinates care delivery.
Measurement criteria
1. The nurse coordinates implementation of the plan.
2. The nurse manages consumer care to maximize independence and quality of care.
3. The nurse assists with identification of options with alternative care.
4. The nurse communicates with the consumer, family, and health care systemduring transitions of care.
5. The nurse advocates for dignified and humane care by the interprofessional team.
6. The coordination of care is document.
Standard 5b: Health teaching and health promotion
The nurse promotes health and a safe environment.
Measurement criteria
1. Health teaching includes healthy lifestyles, risk-reducing behaviors, developmental needs, activities of daily living, and preventive self-care.
2. Health promotion and teaching are appropriate to the patient’s needs.
3. Feedback is received on the effectiveness of health promotion and teachings.
4. Information technology is used to communicate health promotion and disease prevention information.
5. Information is provided to consumers concerning intended effects, as well as potential adverse effects of proposed therapies.
Standard 6: Evaluation
The nurse evaluates the patient’s progress toward attaining outcomes.
Measurement criteria
1. Evaluation is systematic, ongoing, and criteria-based.
2. The patient, partners, and health care providers are involved in the evaluation process.
3. The effectiveness of the plan is evaluated in relation to the patient’s responses and outcomes.
4. The results of the evaluation are documented.
5. Ongoing assessment data are used to revise diagnoses, outcomes, and the care plan as needed.
6. Results of the evaluation are disseminated to the patient and other health care providers involved with the patient’s care in accordance with all laws and regulations.
STANDARDS OFPROFESSIONALPERFORMANCE
Standard
7: Ethics
The nurse integrates ethics in all areas of practice.
Measurement criteria
1. The nurse’s practice is guided by the Code for Ethics for Nurses with Interpretive Statements (ANA, 2001).
2. The nurse preserves and protects patient autonomy, dignity, and rights.
3. The nurse maintains patient confidentiality.
4. The nurse acts as a patient advocate and assists patients in developing skills so they can advocate for themselves.
5. The nurse maintains a therapeutic and professional patient-nurse relationship within professional role boundaries.
6. The nurse is committed to practicing self-care, managing stress, and connecting with self and others.
7. The nurse helps resolve ethical issues, including participating in ethics committees.
8. The nurse reports illegal, incompetent, or impaired practices.
Standard 8: Education
The nurse acquires current knowledge and competency in nursing practice.
Measurement criteria
1. The nurse participates in ongoing educational activities related to knowledge bases and professional issues.
2. The nurse is committed to lifelong learning through self-reflection and inquiry to identify learning needs.
3. The nurse seeks experiences that reflect current practice to maintain current clinical practice and competency.
4. The nurse seeks knowledge and skills appropriate to the practice setting.
5. The nurse seeks experiences and formal and independent learning activities to maintain and develop clinical and professional skills and knowledge.
6. The nurse identifies learning needs based on nursing knowledge, roles assumed, and changing needs of the population.
7. The nurse participates in formal/informal consultation to address issues in nursing practice.
8. The nurse shares educational findings, experiences, and ideas with peers.
9. The nurse contributes to the work environment conducive to the education health care professionals.
10. The nurse maintains professional records that evidence competency and lifelong learning.
Standard 9: Evidence-Based Practice and Research
The nurse uses research findings in practice.
Measurement criteria
1. The nurse uses the best available evidence, including research findings, to guide practice decisions.
2. The nurse participates in research activities as appropriate to her position and education. Such activities may include:
– identifying clinical problems suitable for nursing research
– participating in data collection
– participating in a formal committee or program
– sharing research findings with others
– conducting research
– critiquing research for application to practice
– using research findings in the development of policies, procedures, and standards for patient care
– incorporating research as a basis for learning.
Standard 10: Quality of practice
The nurse systematically enhances the quality and effectiveness of nursing practice.
Measurement criteria
1. Quality is demonstrated by documenting the application of nursing process in a responsible, accountable, and ethical manner.
2. The nurse uses the results of quality-of-care activities to initiate changes in nursing practice and throughout the health care delivery system.
3. The nurse uses creativity and innovation to improve care delivery.
4. The nurse participates in quality improvement activities. Such activities may include:
– identifying aspects of care important for quality monitoring
– identifying indicators used to monitor quality and effectiveness of nursing care
– collecting data to monitor quality and effectiveness of nursing care
– analyzing quality data to identify opportunities for improving care
– formulating recommendations to improve nursing practice or patient outcomes
– implementing activities to enhance the quality of nursing practice
– developing policies, procedures, and practice guidelines to improve quality of care
– participating on interdisciplinary teams that evaluate clinical practice or health services
– participating in efforts to minimize cost and unnecessary duplication
– analyzing factors related to safety, satisfaction, effectiveness, and cost-benefit options
– analyzing organizational barriers
– implementing processes to remove or decrease organizational barriers
– incorporating new knowledge to initiate change in nursing practice if outcomes aren’t achieved.
Standard 11: Communication
The nurse communicates effectively in all areas of practice.
Measurement criteria
1. The nurse assesses communication preferences of health care consumers, families, and colleagues.
2. The nurse assesses his/her own communication skills with health care consumers, families, and colleagues.
3. The nurse seeks continuous improvement of communication and conflict resolution skills.
4. The nurse conveys information to health care consumers, families, the interprofessional team, and others to promote effective communication.
5. The nurse questions rationales and decisions of patient care processes and decisions, discloses observations or concerns related to hazards or errors in care, maintains communication with other providers to optimize safe patient care.
6. The nurse contributes his/her professional perspective with discussions with the interprofessional team.
Standard 12: Leadership
The nurse shows leadership in the practice setting and in the profession.
Measurement criteria
1. The nurse is a teamplayer and a teambuilder.
2. The nurse creates and maintains healthy work environments.
3. The nurse is able to define clear visions, associated goals, and plans to implement and measure progress.
4. The nurse is committed to continual, lifelong learning for self and others.
5. The nurse teaches others to succeed by mentoring and other strategies.
6. The nurse is creative and flexible through changing times.
7. The nurse exhibits energy, excitement, and passion for quality work.
8. The nurse takes accountability of self and others.
9. The nurse inspires loyalty through valuing people as the most precious asset in an organization.
10. The nurse directs the coordination of care across settings and among caregivers, including licensed and unlicensed personnel.
11. The nurse serves on committees, councils, and administrative teams.
12. The nurse promotes the advancement of the profession by participating in professional organizations.
Standard 13: Collaboration
The nurse collaborates with the patient, family, and others in providing patient care.
Measurement
criteria
1. The nurse communicates with the patient, family, and health care providers regarding patient care and the nurse’s role in providing that care.
2. The nurse involves the patient, family, and others in creating a documented plan focused on outcomes and decisions related to care and the delivery of services.
3. The nurse collaborates with others to effect change and get positive outcomes for patient care.
4. The nurse makes and documents referrals, including provisions for continuity of care.
5. The nurse documents plans, communications or collaborative discussions, and rationales for plan changes.
Standard 14: Professional practice evaluation
The nurse evaluates her own nursing practice in relation to professional practice standards and relevant statutes and regulations.
Measurement
criteria
1. The nurse provides culturally and ethnically sensitive and age-appropriate care.
2. The nurse engages in self-evaluation of practice on a regular basis, identifying areas of strength as well as areas where professional development would be beneficial.
3. The nurse seeks constructive feedback regarding his or her own practice.
4. The nurse participates in systematic peer review as appropriate.
5. The nurse takes action to achieve goals identified during the evaluation process.
6. The nurse provides rationales for practice beliefs, decisions, and actions as part of the evaluation process.
7. The nurse interacts with peers and colleagues to enhance his/her professional nursing practice or role performance.
8. The nurse provides peers with formal/informal constructive feedback regarding
Standard 15: Resource utilization
The nurse considers factors related to safety, effectiveness, cost, and impact in planning and delivering patient care.
Measurement criteria
1. The nurse evaluates factors related to safety, effectiveness, availability, cost and benefits, efficiencies, and impact when choosing practice options that would result in the same expected patient outcome.
2. The nurse assists the patient and family in securing appropriate health-related services.
3. The nurse delegates tasks as appropriate.
4. The nurse assists the patient and family in becoming informed consumers about health care treatment.
Standard 16: Environmental Health
The nurse practices in an environmentally safe and healthy manner.
Measurement criteria
1. The nurse maintains knowledge of environmental health concepts.
2. The nurse assesses and promotes a practice environment that reduces associated health risks.
3. The nurse uses scientific evidence to determine safety of products, communicates potential environmental hazards, and advocates for appropriate use of products in health care.
4. The nurse participates in strategies to promote healthy communities.
Reprinted with permission from American Nurses Association (2010) Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Nursesbook.org.
Nurse practice acts
The nurse practice act of each state defines the practice of nursing for that state. Nurse practice acts are broadly worded, and the wording varies fromstate to state. Understanding your nurse practice act’s general provisions will help you stay within the legal limits of nursing practice. With the emergence of more autonomous and expanded roles for nurses, many states have started to revise their nurse practice acts to reflect the greater responsibilities associated with current nursing practice.
Not an easy task
Interpreting your nurse practice act isn’t always easy. One problemstems fromthe fact that nurse practice acts are statutory laws. So, any amendment to a nurse practice act must be accomplished by means of the inevitably slow legislative process. Because of the time involved in pondering, drafting, and enacting laws, amendments to the nurse practice acts lag well behind the changes in nursing.
Anursing dilemma
You may be asked to performtasks that seemto be within the accepted scope of nursing but in fact violate your state’s nurse practice act. Your state’s nurse practice act isn’t a word-for-word checklist on how you should do your work. You must rely on your own education and knowledge of your facility’s policies and procedures.
Limits of practice
Make sure you’re familiar with the legally permissible scope of your nurse practice act, as defined in your state’s nurse practice act and board of nursing rules and regulations. Otherwise, you’re inviting legal trouble.
Licensure and certification
All nurses must be licensed in the state in which they practice. The National Council Licensure Examination (NCLEX) must be taken and passed by all RN candidates. The test is exactly the same in all states.
The practicing nurse may choose to be certified in a specialty area in which she works. Each certification has minimumrequirements, such as education and current work experience. After the nurse has met these requirements and passed an examination, she maintains the certification by continuing education and clinical or administrative practice. (See It’s all in the certification, pages 12 and 13.)
It’s all in the certification
This list includes some of the nursing specialty certifications and their appropriate credentials.
Addictions nursing
Certified Addictions Registered Nurse (CARN)
Advanced practice nursing
Acute Care Nurse Practitioner (APRN, BC)
Adult Nurse Practitioner (ANP)
Family Nurse Practitioner (FNP)
Gerontological Nurse Practitioner (GNP)
Pediatric Nurse Practitioner (PNP)
Psychiatric and Mental Health Nurse Practitioner (PMHNP)
Childbirth educators
Lamaze Certified Childbirth Educator (LCCE)
Critical care nursing
Adult Critical-Care Registered Nurse (CCRN)
Cardiac Medicine Certification (CCRN-CMC)
Cardiac Surgery Certification (CCRN-CMS)
Clinical Nurse Specialist in Acute and Critical Care; Adult, Neonatal, or Pediatric (CCNS)
Neonatal Critical-Care Registered Nurse (CCRN)
Pediatric Critical-Care Registered Nurse (CCRN)
Progressive Care Certified Nurse (PCCN)
Diabetes educators
Certified Diabetic Educator (CDE)
Emergency nursing
Certified Emergency Nurse (CEN)
Flight nursing
Certified Flight Registered Nurse (CFRN)
Gastroenterology nursing
Certified Gastroenterological Registered Nurse (CGRN)
Genetic nursing
Advanced Practice Nurse in Genetics (APNG)
Genetics Clinical Nurse (GCN)
Health care quality nursing
Certified Professional in Healthcare Quality (CPHQ)
HIV-AIDS nursing
AIDS Certified Registered Nurse (ACRN)
Holistic nursing
Holistic Nursing Certification (HNC)
Hospice and palliative nursing
Certified Hospice and Palliative Nurse (CHPN)
Infection control nursing
Certified in Infection Control (CIC)
Infusion nursing
Certified Registered Nurse of Infusion (CRNI)
Lactation consultant
International Board Certified Lactation Consultant (IBCLC)
Legal nurse consulting
Legal Nurse Consulting Certification (LNCC)
Managed care nursing
Certified Managed Care Nurse (CMCN)
Maternal-neonatal nursing
Inpatient Obstetric Nurse (RNC, INPT)
Low Risk Neonatal Nurse (RNC, LRN)
Maternal Newborn Nurse (RNC, MN)
Neonatal Intensive Care Nurse (RNC, NIC)
Medical-surgical nursing
Certified Medical Surgical Registered Nurse (CMSRN)
Nephrology nursing
Certified Nephrology Nurse (CNN)
Neuroscience nursing
Certified Neuroscience Registered Nurse (CNRN)
Nurse administration: Long-termcare
Certified Director of Nursing, Administration in Long-TermCare (CDONA/LTC)
Nurse anesthetist
Certified Registered Nurse Anesthetist (CRNA)
Nurse midwifery and midwifery
Certified Nurse Midwife (CNM)
Nutrition support nursing
Certified Nutrition Support Nurse (CNSN)
Occupational health nursing
Certified Occupational Health Nurse (COHN)
Certified Occupational Health Nurse/Case Manager (COHN/CM)
Oncology nursing
Certified Oncology Nurse (OCN)
Ophthalmic nursing
Certified Registered Nurse Ophthalmology (CRNO)
Orthopedic nursing
Orthopedic Nurse Certified (ONC)
Pediatric nursing
Certified Pediatric Nurse (CPN)
Certified Pediatric Nurse Practitioner (CPNP)
Pediatric oncology nursing
Certified Pediatric Oncology Nurse (CPON)
Perianesthesia nursing
Certified Post Anesthesia Nurse (CPAN)
Certified Ambulatory Perianesthesia Nurse (CAPA)
Perioperative nursing
Certified Nurse Operating Room(CNOR)
RN, First assistant (CRNFA)
Rehabilitation nursing
Certified Rehabilitation Registered Nurse (CRRN, CRRN-A)
School nursing
