Homework answers / question archive / Prepare a two to three page written assignment that includes the following: Introduction to the assignment (sections of the assignment) Describe the importance of the code of ethics in nursing Identify the American Nurses Association Standards of Practice for the licensure you are obtaining (LPN or RN) Conclusion (reflect on the criteria of the assignment) Use at least two credible resources to support your findings

Prepare a two to three page written assignment that includes the following: Introduction to the assignment (sections of the assignment) Describe the importance of the code of ethics in nursing Identify the American Nurses Association Standards of Practice for the licensure you are obtaining (LPN or RN) Conclusion (reflect on the criteria of the assignment) Use at least two credible resources to support your findings

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Prepare a two to three page written assignment that includes the following:

• Introduction to the assignment (sections of the assignment)
• Describe the importance of the code of ethics in nursing
• Identify the American Nurses Association Standards of Practice for the licensure you are obtaining (LPN or RN)
• Conclusion (reflect on the criteria of the assignment)
• Use at least two credible resources to support your findings. For example, one of the resources could be the ANA Standards of Practice, and another resource could be the ANA Code of Ethics. These resources must be integrated into the body of your paper using at least two in-text citations. Be sure to use proper APA format and style.

Format:

• Two to three page written assignment
• Standard American English (correct grammar, punctuation, etc.)
• Logical, original and insightful
• Professional organization, style, and mechanics in APA format
•  

The document linked below contains the project rubric as well as helpful resources

Professional Identity of the Nurse: Scope of Nursing Practice Sally Smith Rasmussen College Author Note This is not needed but optional PROFESSIONAL IDENTITY 2 Role of the Nurse and Scope of Practice For this project, the student nurse will identify the scope of practice for the professional nurse. Professional nursing includes many different areas and levels of nursing (Smith, 2019). Using the Code of Ethics and the American Nurses Association Standards of Practice this paper will provide information on how these documents impact the professional nurse. Use 12-pt Times New Roman throughout. Your paragraph should be at least three sentences. The assignment will …………………………………. Code of Ethics In this section you are going to describe the ANA Code of Ethics (in your own words) and answer why is the Code of Ethics important to the professional nurse. ANA Standards of Practice Using the American Nurses Association’s Standards of Practice you will describe what all nurses across the country are trained to do (please follow the Standards). Conclusion This is where you summarize your paper in the concluding paragraph. PROFESSIONAL IDENTITY 3 References (these are only examples) Buerhaus, P. (2019). Nurse Practitioners: A Solution to America’s Primary Care Crisis. Missouri State Board of Nursing Newsletter, 21(1), 16–23. Retrieved from https://search-ebscohostcom.libauth.purdueglobal.edu/login.aspx?direct=true&db=rzh&AN=134467647&site= ehost-live. (Times New Roman 12-pt font; Reference hanging and double spaced) Creswell, J. W. (2007). Educational research: Planning, conducting, and evaluating quantitative and qualitative research (3rd ed.). Upper Saddle River, NJ: Merrill/Prentice Hall. Heyman, J. C., & Sealy, Y. M. (2011). Providers’ involvement with the New York state healthcare proxy. Educational Gerontology, 37(8), 674-686. doi:10.1080/03601271003723388 Minnesota Board of Nursing. (2018). Advance Practice Nurses. Retrieved from https://mn.gov/boards/nursing/advanced-practice/advanced-practice-registered-nurse(aprn)-licensure-general-information/ Nursing Scope and Standards of Practice 3rd Edition Nursing: Scope and Standards of Practice informs and guides nursing practice and is often used as a reference for: ?? Quality improvement initiatives. ?? Certification and credentialing. ?? Position descriptions and performance appraisals. ?? Classroom teaching and in-service education programs. ?? Members’ orientation programs and regulatory decision-making activities for boards of nursing. It also outlines key aspects of nursing’s professional role and practice for any level, setting, population focus, specialty, and more! In sum, Nursing Scope and Standards of Practice is an authoritative, detailed, and practical discussion of the competent level of nursing practice and professional performance. It is a must-have for every registered nurse. For more information or to order multiple copies, go to www.Nursebooks.org, call 1-800-637-0323 or scan the QR code. 8515 Georgia Avenue, Suite 400 Silver Spring, MD 20910-3492 1-800-274-4ANA (4262) www.Nursingworld.org ISBN-13: 878-1-55810-619-2 SAN: 851-3481 10K 07/2015 Nursing: Scope and Standards of Practice 3rd Edition The premier resource for professional nursing practice, Nursing: Scope and Standards of Practice, 3rd Edition, is informed by the advances in health care and professional nursing today. This keystone publication contains 17 national standards of practice and performance and their competencies. It describes the scope of nursing practice: the who, what, where, when, why, and how of nursing practice activities. Nursing Scope and Standards of Practice 3rd Edition ANA’s Standards of Professional Nursing 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. Standards of Practice 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. Standard 6. Evaluation The registered nurse evaluates progress toward attainment of goals and outcomes. ANA’s Standards of Professional Nursing Practice Standards of Professional Performance 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 the 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. Standard 13. Evidence-based Practice and Research The registered nurse integrates evidence and research findings into practice. The Standards of Professional Performance describe a competent level of behavior in the professional role, including activities related to ethics, culturally 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 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. ©2015 American Nurses Association Source: American Nurses Association. (2015). Nursing: Scope and Standards of Practice (3rd ed.) (pp. 4–5). Silver Spring, MD: ANA. Source: American Nurses Association. (2015). Nursing: Scope and Standards of Practice (3rd ed.) (pp. 5–6). Silver Spring, MD: ANA. ©2015 American Nurses Association Nursing Scope and Standards of Practice 3rd Edition American Nurses Association Silver Spring, Maryland 2015 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: 978-1-55810-620-8    SAN: 851-3481    07/2015 First published: July 2015 Contents Contributors vii Overview of the Content xi Essential Documents of Professional Nursing Additional Content Audience for This Publication xi xi xii Scope of Nursing Practice 1 Definition of Nursing Professional Nursing’s Scope and Standards of Practice Description of the Scope of Nursing Practice Development and Function of the Standards of Professional Nursing Practice Standards of Practice Standards of Professional Performance The Function of Competencies in Standards Integrating the Art and Science of Nursing The What and How of Nursing Tenets Characteristic of Nursing Practice The How of Nursing The Art of Nursing The Science of Nursing When Nursing Occurs Nursing Knowledge, Research, and Evidence-based Practice The Where of Nursing Practice Healthy Work Environments for Nursing Practice Safe Patient Handling and Mobility (SPHM) Fatigue in Nursing Practice Workplace Violence and Incivility Optimal Staffing Supports for Healthy Work Environments High-Performing Interprofessional Teams Key Influences on the Quality and Environment of Nursing Practice 1 1 2 3 4 5 6 6 7 7 9 11 13 16 16 19 21 22 22 22 23 23 27 28 Contents • Nursing: Scope and Standards of Practice, 3rd Ed. • iii Societal, Cultural, and Ethical Dimensions Describe the Why and How of Nursing Model of Professional Nursing Practice Regulation The Code of Ethics for Nurses Specialty Practice in Nursing Professional Registered Nurses Today: The Who of Nursing Statistical Snapshot Licensure and Education of Registered Nurses Advanced Practice Registered Nurse Roles Professional Competence in Nursing Practice Evaluating Competence Professional Trends and Issues Creating a Sustainable Nursing Workforce Nursing Education Technological Advances Population Focus: Redefining Health and Well-being for the Millennial Generation Baby Boomers: Health and Chronic Illness Summary of the Scope of Nursing Practice 31 33 36 37 38 38 41 42 43 45 45 46 47 48 Standards of Professional Nursing Practice 51 Significance of Standards 51 Standards of Practice 53 Standard 1. Assessment Standard 2. Diagnosis Standard 3. Outcomes Identification Standard 4. Planning Standard 5. Implementation Standard 5A. Coordination of Care Standard 5B. Health Teaching and Health Promotion Standard 6. Evaluation 53 55 57 59 61 63 65 66 Standards of Professional Performance 67 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 67 69 71 73 75 76 77 79 81 82 84 iv • Nursing: Scope and Standards of Practice, 3rd Ed. • Contents 48 48 49 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) Appendix D: The Development of Essential Nursing Documents 213 and Professional Nursing 223 Appendix E: Selected Nurse Theorists 227 Appendix F: Culturally Congruent Practice Resources 229 Index 235 Contents • Nursing: Scope and Standards of Practice, 3rd Ed. • v Contributors Nursing: Scope and Standards of Practice, Third Edition, is the product of extensive 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 weekend meeting. The first review process, a 30-day public comment period, followed. 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 Contributors • Nursing: Scope and Standards of Practice, 3rd Ed. • vii 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 viii • Nursing: Scope and Standards of Practice, 3rd Ed. • Contributors 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 organizational affiliates. ANA advances the nursing profession by fostering high standards 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. Contributors • Nursing: Scope and Standards of Practice, 3rd Ed. • ix About Nursesbooks.org, The Publishing Program of ANA Nursesbooks.org publishes books on ANA core issues and programs, including 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 researchers as well as staff nurses in the course of their professional development. x • Nursing: Scope and Standards of Practice, 3rd Ed. • Contributors Overview of the Content Essential Documents of Professional Nursing Registered nurses practicing in the United States have two contemporary professional 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 Overview of the Content • Nursing: Scope and Standards of Practice, 3rd Ed. • xi 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 reference. Legislators, regulators, legal counsel, and the judiciary will also want to examine this content. In addition, the individuals, families, groups, communities, and populations using nursing and healthcare services can use this document to better understand what constitutes the profession of nursing and how registered nurses and advanced practice registered nurses lead within today’s healthcare environment. xii • Nursing: Scope and Standards of Practice, 3rd Ed. • Overview of the Content 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, alleviation 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 descriptions 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 profession. 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 evaluation 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. Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 1 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 provides 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, communities, or populations who are the focus of attention and to whom the registered 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 synonyms 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, abilities, 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 program preparing the nurse for one of the four recognized APRN roles [certified registered nurse anesthetist (CRNA), certified nurse 2 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice 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 preparing the nurse to provide direct care to patients, as well as a component 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 interventions, 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), certified 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 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 or epidemic. As with the scope of practice statement, the standards are subject to formal, periodic review, and revision. Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 3 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, 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 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. 4 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice 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, culturally 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. Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 5 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 demonstrated 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 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 healthcare consumers. Registered nurses use critical thinking to apply the best available evidence and research data to diagnosis and treatment decisions. Nurses 6 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice continually evaluate quality and effectiveness of nursing practice and seek to optimize outcomes. Nursing promotes the delivery of holistic consumer-centered care and optimal 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 priorities. 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” Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 7 (Gallagher-Lepak & Kubsch, 2009, p. 171). While caring for individuals, families, groups, 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; 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, 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. 3. Registered nurses use the nursing process to plan and provide individualized care for healthcare consumers. The nursing process is cyclical and dynamic, interpersonal and collaborative, 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 individualized 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, families, 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 responsible and accountable for communicating and advocating for the planning and care coordination focused on the healthcare consumer, families, and support systems (ANA, 2013a). Collaborative interprofessional team planning is based on recognition of each individual profession’s value and contributions, mutual trust, respect, open discussion, and shared decision-making. 8 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice 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, 2015). 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 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 informatics, 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 incorporating a healthcare consumer-centered approach, the registered nurse collaborates with and treats all healthcare consumers with the utmost respect. The registered 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 expertise, and contextual resources in which nursing is delivered. Closely linked to the best healthcare consumer outcomes is the need for effective interprofessional collaboration. Thus, an essential component of the “how” of registered nursing is care coordination (ANA, 2013a), requiring effective communications 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 prevent errors. Methods can include situation, background, assessment, recommendation (SBAR) (The Joint Commission Enterprise, 2012) and TeamSTEPPSR Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 9 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 responsibilities to the society out of which it grew and continues to serve. Such a professional 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 healthcare 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 preclude illness. • The relationship between the nurse and patient occurs within the context of the values and beliefs of the patient and nurse. • Public policy and the healthcare delivery system influence the health and well-being of society and professional nursing. • Individual responsibility and interprofessional involvement are essential. 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. 10 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice 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 care competently. 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, teaching, 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 promotive, 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 relationship between patient and nurse; highlights the role of the nurse in defining the patient as a unique human being to be valued, respected, nurtured, understood, assisted; and stresses the importance of the connections between the nurse and patient. Human care and caring is viewed as the moral ideal of nursing 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 intersubjective 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 Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 11 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 supports 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, 12 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice 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 nursing 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 holistic 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 policies 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 components, 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 outermost ring reflect how the professional nurse adheres to the Standards of Practice, completes the nursing process, and addresses other nursing practice issues and concerns. Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 13 Standard 1 (S ta 6 n d io ar at lu ) rd is 2 os Eva 17 gn da ia rd lem d Id n Planning g in rs ss N ur o c e P 5 N Pr urs oc ing es s io t ar ta O en nd e n ut t i com St fi c e at an ion Imp Sta 3 Nursing Process Nursing Process Standard 4 = Feedback loop 14 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice da nd 7– St ar an D Sta nd s ssment Asse nce N Pr urs oc ing es s ds Per forma St an of ional d r Pr ss ofe g in rs ss N ur o c e P da Figure 1. The Nursing Process and the Standards of Professional Nusing Practice 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 components correspond to these standards. Standard Standard 1 Standard 2 Standard 3 Standard 4 Standard 5 Standard 6 Nursing Process Component Assessment Diagnosis Outcomes Identification Planning Implementation 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 Standard 7 Standard 8 Standard 9 Standard 10 Standard 11 Standard 12 Standard 13 Standard 14 Standard 15 Standard 16 Standard 17 Professional Performance Ethics Culturally Congruent Practice Communication Collaboration Leadership Education Evidence-based Practice and Research Quality of Practice Professional Practice Evaluation Resource Utilization Environmental Health Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 15 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 analysis 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 prospectively 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 consumer; 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 16 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice Nightingale provided a foundation for nursing and the basis for autonomous nursing practice as distinct from medicine. Nightingale 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 advanced degrees in nursing education, and nursing research was limited to studies of nurses and nursing education. 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. In the last half of the 20th 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. Theories are patterns that guide the thinking about, being, and doing of nursing. Theories provide structure and substance to organize knowledge, guide practice, enhance the care of healthcare consumers, and guide inquiry to advance the science and practice of the profession. They must be flexible and dynamic to keep pace with the growth and changes in the discipline and the practice of nursing. The further development and expanded use of nursing theories and models continues today and is essential to the ongoing evolution of nursing. Appendix E includes a list of selected nurse theorists and their work. Nursing, as an art and a science, reflects all the ways of knowing [e.g, empirical, ethical, personal, and aesthetic as identified by Carper (1978)], gleaned Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 17 from: scientific investigations, accumulated and graded evidence, qualitative analysis, narratives, appreciative inquiry, case studies, interpersonal and cultural sensitivity, insight, sociopolitical awareness, intuition, experience, reflection, introspection, creative thinking, philosophical analyses, and spirituality. The practice of nursing is rooted in evidence-based knowledge. Evidence-based practice (EBP) is a life-long problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health consumer’s history and condition, as well as healthcare resources; and patient/family/group/ community/population preferences and values. When evidence-based practice is delivered in a context of caring and a culture, as well as an ecosystem or environment that supports it, the best clinical decisions are made to yield positive healthcare consumer outcomes (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014). While outcomes are essential, the EBP process itself provides a framework for clinicians, educators, and nurse researchers to ponder, and then expertly construct the most relevant, patient-centered, and testable questions, which in turn yield important practice guidelines for optimizing patient outcomes. The EBP process, first and foremost, promotes the asking of the question, and then utilizes the scientific framework of peer-reviewed literature searches, critical appraisal, and the foundation of nursing knowledge to reach an endpoint that can be reproduced, translated, and shaped into new knowledge. Because of Florence Nightingale’s initial influence, nursing also relies on epidemiologic models of practice and the environment or its variations. When such models are used, cases are tracked, patients/families/communities are treated, and prevention strategies are employed. More recently, nurses within public health are conscious of and employ strategies that consider the entire ecological system to optimize health and prevent or treat illness. Regardless of the theoretical knowledge base upon which nursing practice is derived, the knowledge fits within the multidimensional nursing process. The nursing process appears linear on first inspection, but is also iterative and incremental, depending upon individual, family, group, community, or population responses. Evidence-based competencies are foundational to the nursing process. For example, questions regarding clinical practices for the purpose of improving the quality of care may query assessment, diagnosis, planning, outcomes identification, implementation, evaluation, or a combination of these. Describing clinical problems using internal evidence relates to assessment data, diagnosis, and outcomes identification. Evidence-based competencies work hand in hand with outcome measurement, including cost measures (e.g., costs averted, cost savings), nursing-sensitive quality indicators, and the 2001 IOM outcome 18 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice categories of clinical effectiveness, safety, efficiency, patient-centeredness, timeliness, and equitability (IOM, 2001). Outcome measures may also refer to diagnostic-specific nursing outcomes as stipulated in Nursing Outcomes Classification (Moorhead, Johnson, Maas, & Swanson, 2012). Knowledge translation is also known as evidence-based decision-making, research utilization, innovation diffusion, knowledge transfer, research dissemination, research implementation, and research uptake (Estabrooks et al., 2006, p. 28). Translation of knowledge to practice settings aims to achieve identified outcomes for systems, providers, educators, healthcare consumers, and other stakeholders. This effort continues to be one of the most daunting challenges to registered nurses, but provides exciting opportunities. Translation of research into practice is a science unto itself, known as translational research. Nurses are at the forefront of this work as they implement evidence-based practices into clinical care, lead research teams to investigate barriers and facilitators of knowledge translation, and advocate at all policy levels for the adoption of these practices throughout the healthcare system. The surge in the scholarly evaluation of evidence-based practice by the expanding ranks of nurses prepared at the doctoral level has contributed to enhanced utilization of evidence-based practice or translation of research into practice. The failure to employ a theoretically driven knowledge translation plan prevents the development of testable and useful interventions reflecting thoughtful consideration of the nursing process to the target of the intervention. Estabrooks et al. (2006) provide an overview of selected knowledge translation theories spanning the individual healthcare consumer, team, organization, community, and populations. Newhouse (2010) reminds nurses that inclusion of a cost analysis is key when recommending any knowledge translation plan to healthcare consumers or decision-making bodies. The Where of Nursing Practice Nursing occurs in any environment where there is a healthcare consumer in need of care, information, or advocacy. The following content describes a sampling of settings and environments for today’s evolving and expanding nursing presence. Originally nurses provided nursing services to patients and their families in home settings. Public health nursing resources focused on prevention initiatives and support of community and population health. Establishment of hospitals as inpatient centers for acute care services provided new opportunities for registered nurses. Today home health, post-acute care, assisted living, and long-term care facilities, and community-based living, outpatient, and ambulatory settings are gaining in popularity. This evolution has greater importance as transitions in care, cost reduction measures, financial penalties for adverse outcomes, and healthcare reform initiatives materialize. New Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 19 technologies have enabled establishment of ambulatory surgical centers and interventional services providers, such as facilities for cardiology and radiology studies and therapies, and infusion and dialysis centers. Nursing practice in correctional facilities, military organizations, air and ground transport services, and emergency preparedness and disaster support is less commonly identified. Nursing practice in educational settings is represented as school and college health nursing services or academic and professional development and continuing education faculty roles. Other nursing practice settings include occupational health departments, public and private organizations or businesses, faith communities, research and quality improvement organizations, administrative and informatics positions, and entrepreneurial ventures. Smartphone and telehealth technologies, wearable devices and remote monitoring, as well as social media and the Internet, are transforming health care and nursing practice to virtual, “always on” access. Such technology solutions enable nursing practice to move from local settings to national, international, global, and even outer space venues. Advocacy is fundamental to nursing practice in all settings. Advocacy is “the act or process of pleading for, supporting, recommending a cause or course of action” (ANA, 2015, p. 41). Advocacy occurs at the individual, interpersonal, organization and community, and policy levels (Earp, French, & Gilkey, 2008). At the individual level, the nurse engages in informing healthcare consumers so they can consider actions, interventions, or choices in light of their own personal beliefs, attitudes, and knowledge to achieve the desired outcome. Thus the healthcare consumer learns self-management and patient-centered decision-making. At the interpersonal level, the nurse empowers healthcare consumers by providing emotional support, attainment of resources, and necessary help through interactions with families and significant others in their social support network. At the organization and community level, the nurse supports cultural transformation of organizations, communities, or populations when present. Registered nurses firmly believe it is their obligation to help improve environmental and societal conditions related to health, wellness, and care of the healthcare consumer. Such issues have included but are not limited to protective labor laws, minimum wage, communicable disease programs, immunizations, well-baby and child care, women’s health, violence, reproductive health, and end-of-life care. Finally, at the policy level, the nurse translates the consumer voice into policy and legislation that address such issues as control of healthcare access, regulation of health care, protection of the healthcare consumer, and environmental justice. Thus advocacy also occurs when registered nurses represent professional nursing practice in advocating for the removal of barriers to 20 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice permit practice to the full extent of their education and training. Registered nurses also advocate as seated members in state and national legislative bodies, IOM committees, and organizational leadership level boards; as they lobby for healthcare issues and resources; and when they join with vulnerable communities fighting industry and dilapidated housing that threatens the health of individuals, group, communities, and populations. Registered nurses are also advocates when addressing malpractice concerns and in their roles as legal nurse consultants or when engaged in legal practice as nurse attorneys. The nurse understands that “place matters” because of the environmental impact of where people grow, learn, work, and reside. Advocacy, as defined by nursing, can take place wherever healthcare consumers exist or their needs require representation (e.g., streets to the halls of legislatures). There is ample need for professional nurses to continue advocacy and lobbying efforts for the evaluation and restructuring of health care, reimbursement and value of nursing care, funding for nursing education, identifying the role of nurses and 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, health care, and the nursing profession. Healthy Work Environments for Nursing Practice A healthy work environment is one that is safe, empowering, and satisfying, not merely the absence of real and perceived physical or emotional threats to health, but a place of physical, mental, and social well-being, supporting optimal health and safety. A culture of safety is paramount, in which all leaders, managers, healthcare workers, and ancillary staff have a responsibility as part of the interprofessional team to perform with a sense of professionalism, accountability, transparency, involvement, efficiency, and effectiveness. All must be mindful of the health and safety of both the healthcare consumer and the healthcare worker in any setting providing health care, providing a sense of safety, respect, and empowerment to and for all persons. Nurses and other healthcare professionals are challenged with the complexities and intensity of work inherent in all healthcare settings. Many factors influence healthcare work environments, including economic challenges, the rapidity with which new information and healthcare technologies are introduced into healthcare settings, demographic shifts, aging and obesity of both the nursing workforce and the general population, the growth of transitional care across all settings, and the impact of healthcare reform. These factors have created significant changes, sometimes perceived as barriers to achieving healthy work environments that support and promote the best patient care and the health and well-being of the nurse. Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 21 Safe Patient Handling and Mobility (SPHM) The establishment of a healthy work environment is predicated on a culture of safety. Nurses in all specialty areas are at varying risk for musculoskeletal and other injuries, especially due to lifting and patient positioning without the right equipment, education, and training. The ANA supports the position that manual patient handling must be eliminated to ensure nurses and other healthcare workers are providing care in a safe work environment (ANA, 2008). The Safe Patient Handling and Mobility Interprofessional National Standards (ANA, 2012c) has established standards that address the responsibility of employers and healthcare professionals in establishing an effective safe patient handling and mobility program. Fatigue in Nursing Practice The 2015 Code of Ethics for Nurses with Interpretive Statements affirms that all nurses, regardless of specialty, have an ethical responsibility to report to work alert, well-rested, and prepared to give safe, quality patient care. Nursing work can be both physically and emotionally exhausting. Long and variable hours, heavy patient loads, and complex care needs that require multi-tasking are just some of the challenges that nurses face every day. Research has demonstrated that fatigue has a major impact on the health and safety of nurses, and on clinical care outcomes. ANA’s fatigue position statement (2014c) identifies important strategies that must be implemented by both employers and nurses to reduce the occurrence of fatigue in the workplace. Workplace Violence and Incivility Healthcare workers have a fivefold risk of experiencing workplace violence when compared to the overall workforce (National Institute for Occupational Safety and Health, 2013a). The presence of overt and covert workplace violence, bullying, and incivility has a significant impact on both the individual nurse and the overall work environment that includes increased time away from work, higher turnover rates among nurses and other team members, and sub-optimal patient outcomes. Nurses must advocate for policies and procedures that address the issue of workplace violence and incivility. The American Nurses Association maintains the position that nurses have the right to work in an environment free of abusive behavior and violence (ANA, 2012b). The National Institute for Occupational Safety and Health (NIOSH) provides extensive resources, training, and education specific to nurses to assist in the development of a comprehensive workplace violence prevention program (NIOSH, 2013a). 22 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice Optimal Staffing The issue of optimal staffing has a significant impact on the work environment and continues to be a priority concern of nurses at all levels of practice (ANA, 2014a). Economic constraints, shortages of qualified staff, shortened lengths of stay, and patient care needs that are increasingly complex, are all factors that contribute to the challenges inherent in creating and sustaining staffing models that promote optimal staffing for safe patient care. ANA’s Principles for Nurse Staffing (ANA, 2012a) provides a framework to assist nurses at all levels in evaluating and revising current staffing models to improve the work environment for nurses, and ultimately, to improve outcomes of clinical care. This framework includes principles related to: • Healthcare consumers • Registered nurses and other staff • Organization and workplace culture • The practice environment • Staffing evaluation Optimal staffing is a critical component of a healthy work environment. Contemporary staffing models should include elements that support team-based care, which has been identified as a highly effective model that promotes safe, effective, and efficient care (Agency for Healthcare Research and Quality, 2008). Innovative strategies that incorporate the best evidence and a collaborative team approach provide the greatest opportunity to overcome barriers and improve nurse satisfaction and patient care. Nurses who work as independent contractors in homes and other uncontrolled settings are responsible for avoiding fatigue and accessing team members and other resources as needed. Supports for Healthy Work Environments The following initiatives, frameworks, models, and constructs demonstrate characteristics important to the development and maintenance of an exemplary work environment. American Nurses Association (ANA) The initial ANA Healthy Nurse™ framework began in 2009. The definition and constructs are as follows: ANA defines the healthy nurse as one who actively focuses on creating and maintaining a balance and synergy of physical, intellectual, emotional, social, spiritual, personal Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 23 and professional well-being. Healthy nurses live life to the fullest capacity, across the wellness–illness continuum, as they become stronger role models, advocates, and educators, personally, for their families, their communities and work environments, and ultimately for their patients. (ANA, 2013b) The five Healthy Nurse™ constructs include: Calling to Care: Caring is the interpersonal, compassionate offering of self by which the healthy nurse builds relationships with patients and their families, while helping them meet their physical, emotional, and spiritual goals, for all ages, in all healthcare settings, across the care continuum. Priority to Self-Care: Self-care and supportive environments enable the healthy nurse to increase the ability to effectively manage the physical and emotional stressors of the work and home environments. Opportunity to Role Model: The healthy nurse confidently recognizes and identifies personal health challenges in themselves and their patients, thereby enabling them and their patients to overcome the challenge in a collaborative, non-accusatory manner. Responsibility to Educate: Using non-judgmental approaches, considering adult learning patterns and readiness to change, the healthy nurse empowers themselves and others by sharing health, safety, wellness knowledge, skills, resources, and attitudes. Authority to Advocate: The healthy nurse is empowered to advocate on numerous levels, including personally, interpersonally, within the work environment and the community, and at the local, state, and national levels in policy development and advocacy. American Nurses Credentialing Center (ANCC Programs) The Magnet Recognition Program The Magnet Recognition Program® provides a framework for practice that has a significant impact on the professional nursing work environment. To achieve and maintain Magnet recognition, Magnet®-designated facilities must demonstrate the following model components: Transformational Leadership: Transformational leaders have the ability to articulate a strong vision that aligns strategic goals across the organization. They inspire their followers to succeed by empowering them to achieve professional goals and developing them professionally into leaders. 24 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice Structural Empowerment: Structural empowerment is achieved by developing structures and processes that support a decentralized environment, include a shared governance and decision-making framework, support lifelong learning, professional development, certification and academic advancement, and promotes the voice of nursing by ensuring that nurses, including the Chief Nursing Officer (CNO), are included in decision-making at all levels of the organization. Exemplary Professional Practice: This demonstrates what professional nursing practice can achieve with structures and processes that support professional roles of the nurse as consultant, teacher, and interprofessional team member. Exemplary professional practice also promotes professional models of care, autonomy, quality improvement, and quality of care. New Knowledge, Innovation, and Improvements: To evolve and innovate, organizations must proactively integrate research and best evidence into clinical and operational practice. Empirical Outcomes: Recognizing that outcomes are essential to establishing and maintaining organizational excellence, the 2008 Magnet Manual reflected that significant shift in focus and included outcome standards that have carried through to the 2014 Magnet Manual. Nearly half of the standards in the current manual are outcome-focused. (ANCC, 2014) Pathway to Excellence Program The American Nurses Credentialing Center developed the Pathway to Excellence® Program to recognize healthcare organizations that demonstrate successful implementation of the Pathway to Excellence® structure and process standards that promote a healthy work environment and meet the Pathway Practice Standards: 1. Nurses control the practice of nursing 2. The work environment is safe and healthy 3. Systems are in place to address patient care and practice concerns 4. Orientation prepares nurses for the work environment 5. The CNO is qualified and participates in all levels of the organization 6. Professional development is provided and used 7. Equitable compensation is provided 8. Nurses are recognized for achievements 9. A balanced lifestyle is encouraged Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 25 10. Collaborative relationships are valued and supported 11. Nurse managers are competent and accountable 12. A quality program and evidence-based practice are used. (ANCC, 2012) American Association of Critical-Care Nurses Standards The American Association of Critical-Care Nurses has identified six standards for establishing and maintaining healthy work environments that remain unchanged today: Skilled Communication: Nurses must be as proficient in communication skills as they are in clinical skills. True Collaboration: Nurses must be relentless in pursuing and fostering a sense of team and partnership across all disciplines. Effective Decision-making: Nurses are seen as valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations. Appropriate Staffing: Staffing must ensure the effective match between healthcare consumer needs and nurse competencies. Meaningful Recognition: Nurses must be recognized and must recognize others for the value each brings to the work of the organization. Authentic Leadership: Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in achieving it. (American Association of Colleges of Nursing, 2005, p. 13) American Holistic Nurses Association (AHNA Core Values) The AHNA/ANA’s Holistic Nursing: Scope and Standards of Practice, Second Edition (2013) includes five core values that promote the importance of caring for oneself, and the creation of a therapeutic environment: Core Value 1. Holistic Philosophy, Theories, and Ethics Core Value 2. Holistic Caring Process Core Value 3. Holistic Communication, Therapeutic Healing Environment, and Cultural Diversity 26 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice Core Value 4. Holistic Education and Research Core Value 5. Holistic Nurse Self-Reflection and Self-Care Samueli Institute The Samueli Institute (2010) has conducted extensive research on healing environments and has identified four domains that comprise an optimal work environment: Domain 1. Internal Environments: Focus on the health and wellness of self, intentionality in caring, and personal wholeness. Domain 2. Interpersonal Environments: Focus on the cultivation of healing relationships, both collegial and at the organizational level. Domain 3. Behavioral Environments: Focus on healthy lifestyle and team-based, person- and family-centered care. Domain 4. External Environments: Focus on actions that support external healing environments and a healthy planet. High-Performing Interprofessional Teams Nurses are familiar with collaborative work groups that foster collegial relationships focused on sharing of specialized skills and information. In this paradigm, clinicians are rewarded for individual performance rather than team-based results. This does not yet reflect an evolution to high-performing interprofessional teams: interprofessional competency in health care has been defined as: integrated enactment of knowledge, skills, and values/attitudes that define working together across the professions, with other health care workers, and with patients, along with families and communities, as appropriate to improve health outcomes in specific care contexts. (Interprofessional Education Collaborative Expert Panel, 2011, p. 2) The Expert Panel identified four interprofessional collaborative practice domains, which are both community and population-oriented and patient- and family-centered. These competency domains include: • Values/Ethics for Interprofessional Practice • Interprofessional Teamwork and Team-based Practice • Interprofessional Communication Practices Roles, and • Responsibilities for Collaborative Practice Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 27 The Institute of Medicine (IOM) identifies multiple issues inherent in any care delivery model that does not include high performance teamwork, including adverse events related to inadequate communication and handoffs, and the potential for duplication and waste resulting in higher healthcare costs (Mitchell et al., 2012). A study performed at the Massachusetts Institute of Technology identified effective communication patterns as the single most critical factor in determining the degree of success of work teams (Pentland, 2012). The Agency for Healthcare Research and Quality (AHRQ) has identified Team-based Care as a highly effective care delivery model that promotes safe, effective, and efficient health care (AHRQ, 2008). Care coordination has been identified as a “traditional strength of the nursing profession” (IOM, 2010), and nurses have been identified as having the “critical history, knowledge, and expertise needed to assure that care coordination achieves the goals set forth for it in the national quality agenda” (Lamb, 2014, p. 3). Nurses have demonstrated the positive impact of nurse-led teams (Watts et al., 2009). Many reference Tuckman’s 1965 Forming, Storming, Norming, Performing Model when describing the characteristics and evolution of a successful high performing team (Eyre, n.d.). He identified that high performing teams complete four developmental stages: forming, storming, norming, and performing, and added a fifth stage, adjourning, in the 1970s. RNs and APRNs are often key contributors and leaders in each stage. Key Influences on the Quality and Environment of Nursing Practice Many organizations seek to influence society and nursing through similar and/ or shared purposes, goals, and agendas. Each nurse must be aware of historical, contemporary, and future internal or external influences that can impact nursing practice and those served. Validation through scientific, nursing-focused inquiry enables nursing practice to proactively evolve to address global influences. Such influences include, but are not limited to, the Tri-Regulator Collaborative, Institute of Medicine, the National Council of State Boards of Nursing, the Robert Wood Johnson Foundation (RWJF), and others. The recently established Tri-Regulator Collaborative is comprised of the leading organizations representing the licensing boards of the United States that regulate the practice of medicine, pharmacy, and nursing, the Federation of State Medical Boards, National Association of Boards of Pharmacy, and National Council of State Boards of Nursing. (Tri-Regulator Collaborative, 2014) 28 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice Its aim is to improve the quality of health care in the United States through a team-based approach to patient care and it is projected to have increasing impact on professional practice and education. In an article released by the Robert Wood Johnson Foundation, October 2014, Melanie Dreher, PhD, RN, FAAN, is quoted as saying: Nursing is the largest and most trusted healthcare profession, and nurses spend more time with patients than other providers and see patients in their broader environments—in their communities and homes and with family members. … More nurse leaders are needed in all sectors to share their unique insights into factors that affect health and health care and the best ways to engage caregivers and loved ones in patient care. No one understands patients—the person part of the patient—the way nurses do. (Dreher, 2014) To address issues in health care, the Institute of Medicine, a branch of the National Academy of Sciences, commissions reports on scientific topics. Its reports and other publications are most often directed toward universal healthcare practice and sometimes explicitly to nursing, and provide a framework for 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 suggested 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, urged 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 to whom they provide care. Keeping Patients Safe: Transforming the Work Environment of Nurses is a key report that considers how nurses’ interactions with their workplace help or hinder 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 identified leadership and management, the workforce, work processes, and organizational culture as the components of Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 29 the workplace most influential on nursing and patient outcomes. This report proposes changes to those components that would lead to better outcomes for patients and nurses (IOM, 2004). To date, few work environments have achieved all 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. The Future of Nursing: Leading Change, Advancing Health (IOM, 2010) and the subsequent Future of Nursing Campaign are providing strategies for nursing and nurses to become more influential, visibly active, outcome-oriented, and positioned in strategic positions in the public arena. The first recommendation in the report addresses the need to remove scope of practice barriers. Nurses are called to engage in activities that target major stakeholders, such as Congress, Centers for Medicare and Medicaid Services, and state legislative and regulatory bodies, to remove barriers and enable nurses to practice at the highest level of their education and training and promote enhanced consumer access to quality health care. Action related to nursing education has created momentum and new partnerships between undergraduate programs and academia and practice partnerships. Revised goals in nursing education include eventual achievement of a doctorate in nursing practice or a Doctor of Philosophy in Nursing as the terminal degree for the profession. This report specifically recommends increasing the amount of nurses with Bachelor of Science in Nursing (BSN) degrees to 80% by 2020 (Recommendation 4) and to double the amount of doctorally prepared nurses by 2020 (Recommendation 5). A renewed respect for lifelong learning has been developed in the various communications provided to the profession of nursing. Additionally, The Future of Nursing has identified, through survey and questioning, the lack of registered nurses who serve on opinion-generating and policy-making boards. Such boards are responsible for provision of direction for the nation’s health care and rely on the Affordable Care Act and Medicaid Expansion as a formidable plank for their decision-making process. IOM reports that continue to influence nursing practice include others, such as Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life; Best Care at Lower Cost: The Path to Continuously Learning Health Care in America; Primary Care and Public Health: Exploring Integration to Improve Population Health; and Health IT and Patient Safety: Building Safer Systems for Better Care. Nurses are increasingly important participants and contributors in the work of the IOM. Healthy People 2020 highlights the importance of addressing the social determinants of health identified as these five key areas: economic stability, education, social and community context, health and health care, and neighborhood 30 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice and built environments. Each determinant is characterized by a number of critical components and key issues. More details are available at http://www. healthypeople.gov/2020/topics-objectives/topic/social-determinants-health. Although nursing defines its own scope and standards of practice in care delivery systems and education environments, the profession is greatly enhanced through the contributions of these external influences. The external influences affecting nursing are too numerous to list but each can serve as a catalyst for collaboration, promote partnerships in healthcare delivery, and reflect substantive support for nurses and nursing practice. Societal, Cultural, and Ethical Dimensions Describe the Why and How of Nursing The need for health care is universal and transcends differences with respect to the culture, values, and preferences of the individual, family, group, community, and population. Diversity characterizes today’s healthcare environment. 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 life span. To effectively promote meaningful outcomes, nurses must embrace that diversity and engage in culturally congruent practice. Culturally congruent practice is the application of evidence-based nursing that is in agreement with the preferred cultural values, beliefs, worldview, and practices of the healthcare consumer and other stakeholders. Cultural competence represents the process by which nurses demonstrate culturally congruent practice. Nurses design and direct culturally congruent practice and services for diverse consumers to improve access, promote positive outcomes, and reduce disparities. A number of theories and models outline how culturally congruent practice may be implemented. Examples include, but are not limited to: • Andrews/Boyle Transcultural Interprofessional Practice Model (TIP), developed by Margaret M. Andrews and Joyceen S. Boyle (Andrews & Boyle, 2015 in press) • The Process of Cultural Competence in the Delivery of Health Services, Model, developed by Josepha Campinha-Bacote (Campinha-Bacote, 2011b) • Culture Care Diversity and Universality, developed by Madeleine Leininger. [Leininger & McFarland (2002), and McFarland & Wehbe-Alamah (2015)] Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 31 • Giger & Davidhizar’s Transcultural Assessment Model, developed by Joyce Newman Giger & Ruth Elaine Davidhizar (Giger & Davidhizar, 2008) • Jeffreys’s Cultural Competence and Confidence (CCC) Model, developed by Marianne R. Jeffreys (Jeffreys, 2010) • Purnell Model for Cultural Competence, developed by Larry Purnell (Purnell, 2013) • The HEALTH Traditions Model, developed by Rachel E. Spector, includes three assessment tools and one interview guide (Spector, 2013). Some of these authors have provided tools and guides for implementation of culturally congruent practice. For example, many nurses have found the mnemonic ASKED (Awareness, Skill, Knowledge, Encounters, Desire) a helpful resource (http://www.transculturalcare.net/cultural_competence_model.htm). Campinha-Bacote used a case study (Vignette: “To Coin, or Not to Coin: That Is the Question”) to demonstrate how nurses can partner with consumers in resolving cultural conflict between the consumer’s culture and the provider’s evidence-based practice guidelines (2011b). See Appendix F for further resources about culturally congruent practice. Registered nurses enable and promote the interprofessional and comprehensive care provided by healthcare professionals, paraprofessionals, and volunteers. Nurses also engage in consultation and collaboration with other healthcare 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 team member’s individual efforts. Registered nurses, regardless of specialty, role, or setting, are accountable for nursing judgments made and actions taken in the course of their nursing practice. Therefore, the registered nurse is responsible for assessing one’s own 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 must be encouraged to always seek and maintain certification when it is available in their areas of practice. Registered nurses and members of various professions exchange knowledge and ideas about how to deliver safe and high-quality health care, resulting in overlaps and constantly changing professional practice boundaries. In accordance with recommendations from professional organizations that team-based care improves safety, satisfaction, quality, and efficiency, nurses are contributing to and leading initiatives in the provision of team-based patient-centered 32 • Nursing: Scope and Standards of Practice, 3rd Ed. • Scope of Nursing Practice care and development of a collegial work environment (IECEP, 2011). Such 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. Given the current economic environment, nurses strive to be fiscally responsible in the allocation and utilization of resources. Nurses recognize resources are limited and unequally distributed, and the potential for better access to care requires innovative approaches, such as treating healthcare consumers in nurse-managed healthcare centers and telehealth services. As members of a profession, registered nurses promote equitable distribution, access to, and availability of healthcare services throughout the nation and the world. Legislative changes have expanded the role of nurses as advocates in giving voice to ethical issues for the profession and those for whom they provide care. Issues originating at the bedside become evident as patients progress through the continuum of care. Nurses engage in discussion of these issues in diverse consumer and professional media. As new challenges arise in response to advances in technology, changing roles, and regulatory amendments, nurses promote discussion of patient-centered care, achieve consensus for decision-making, empower the community to action, and mentor development of self-care skills based on the profession’s responsibility to the health and well-being of humanity. Registered nurses are bound by a professional code of ethics (ANA, 2015) and regulate themselves as individuals through a collegial review of practice. Such a review fosters the refinement of knowledge, skills, and clinical decision-making at all levels and in all areas of nursing practice. Self-regulation by the profession of nursing assures quality of performance, which is the heart of nursing’s social contract (ANA, 2010b). 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 nurse and the professional and specialty nursing organizations to their members and the public to define the scope and standards of nursing practice. Scope of Nursing Practice • Nursing: Scope and Standards of Practice, 3rd Ed. • 33 Figure 2. Model of Professional Nursing Practice Regulation QUALITY EVID ENCE E AF TY S Source note: This is a revision of a model published first in ANA, 2006, then revised in Styles, Schumann, Bickford, & White, 2008; ANA 2010a. 34 • Nursing: Scope and Standards of Practice, 3rd Ed. ...