Nursing: Scope and Standards of Practice, 4th Edition

Nursing

Scope and Standards of Practice

4th Edition

The American Nurses Association (ANA) is a national professional association. This publication reflects the position of ANA regarding the scope and standards of nursing practice and should be reviewed in conjunction with state board of nursing regulations. State law, rules, and regulations govern the practice of nursing, while Nursing: Scope and Standards of Practice, 4th Edition guides registered nurses in the application of their professional skills and responsibilities.

About the American Nurses Association

The American Nurses Association (ANA) is the only full-service professional organization representing the interests of the nation’s 4.2 million registered nurses through its constituent/state nurses associations and its organizational affiliates. The 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.

American Nurses Association

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Silver Spring, MD 20910

Copyright © 2021 ANA. All rights reserved. No part of this book may be reproduced or used in any form or any means, electronic or mechanical, including photocopying and recording, or by any information storage and retrieval system, without permission in writing from the publisher.

ISBNs

Print 978-0-9993088-6-8

ePDF 978-0-9993088-7-5

ePUB 978-0-9993088-8-2

Mobi 978-0-9993088-9-9

SAN: 851-3481

Contents

Contributors

Nursing Scope and Standards Workgroup, 2019–2020

Others

ANA Committee on Nursing Practice Standards—Reviewers

ANA Staff

About the American Nurses Association

About the American Nurses Association Publishing Program

Scope of Nursing Practice

Definition of Nursing

Other Definitions

Description of the Scope of Nursing Practice

Development and Function of the Standards of Professional Nursing Practice

The Art and Science of Nursing

The Art of Nursing

Care and Caring in Nursing Practice

Professional Nursing Model

Nursing Process

Ethics for Nurses

Code of Ethics Provisions

Ethical Decision-Making Models

Case Study: Using the Nursing Process in Ethical Situations

Respect, Equity, Inclusion, and Social Justice

The Science of Nursing

Nursing Knowledge and Scholarly Inquiry

The How of Nursing

Ways

Processes

Means

Methods

Manner

Advocacy

High-Performing Interprofessional Teams

Regulation of Nursing Practice

Context and Environment: When Nursing Occurs

Professional Registered Nurses Today: The Who of Nursing

Licensure and Education of Registered Nurses

Certified Nurse-Midwife (CNM)

Certified Nurse Practitioner (CNP)

Certified Registered Nurse Anesthetist (CRNA)

Clinical Nurse Specialist (CNS)

Professional Competence, Self-Determination, and Professional Identity in Nursing

Professional Competence

Self-Determination

Professional Identity

The Professional Responsibility of Mentoring in Nursing: Paying It Forward

A Potpourri of Opportunities for the Future

Environment

Disaster Planning and Management

Reimbursement and Cost-Effective Care Economic Structures

Structural Competency

Protection of Healthcare Workers

Health

Quality of Life

Aging in Place

Palliative Care Conversations

Reimagining Nursing Initiative

Standards of Professional Nursing Practice

Significance of Standards

The Function of Competencies in Standards

Standards of Practice

Standard 1. Assessment

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse

Additional Competencies for the Advanced Practice Registered Nurse

Standard 2. Diagnosis

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse

Additional Competencies for the Advanced Practice Registered Nurse

Standard 3. Outcomes Identification

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse, Including the Advanced Practice Registered Nurse

Standard 4. Planning

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse

Additional Competencies for the Advanced Practice Registered Nurse

Standard 5. Implementation

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse

Additional Competencies for the Advanced Practice Registered Nurse

Standard 5A. Coordination of Care

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse

Additional Competencies for the Advanced Practice Registered Nurse

Standard 5B. Health Teaching and Health Promotion

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse, Including the Advanced Practice Registered Nurse

Standard 6. Evaluation

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse, Including the Advanced Practice Registered Nurse

Standards of Professional Performance

Standard 7. Ethics

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse, Including the Advanced Practice Registered Nurse

Standard 8. Advocacy

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse

Additional Competencies for the Advanced Practice Registered Nurse

Standard 9. Respectful and Equitable Practice

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse, Including the Advanced Practice Registered Nurse

Standard 10. Communication

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse, Including the Advanced Practice Registered Nurse

Standard 11. Collaboration

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse, Including the Advanced Practice Registered Nurse

Standard 12. Leadership

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse, Including the Advanced Practice Registered Nurse

Standard 13. Education

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse, Including the Advanced Practice Registered Nurse

Standard 14. Scholarly Inquiry

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse, Including the Advanced Practice Registered Nurse

Standard 15. Quality of Practice

Competencies 101

Additional Competencies for the Graduate-Level Prepared Registered Nurse

Additional Competencies for the Advanced Practice Registered Nurse

Standard 16. Professional Practice Evaluation

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse

Additional Competencies for the Advanced Practice Registered Nurse

Standard 17. Resource Stewardship

Competencies

Additional Competencies for the Graduate-Level Practice Registered Nurse, Including the Advanced Practice Registered Nurse

Standard 18. Environmental Health

Competencies

Additional Competencies for the Graduate-Level Prepared Registered Nurse, Including the Advanced Practice Registered Nurse

Glossary

References

Appendix A. Ethics, Morals, and Ethical Theories and Approaches

Ethics and Morals

Ethical Theories and Approaches

Consequentialism and Deontology

Ethical Principlism

Ethics of Care and Virtue Ethics

Appendix B. Selected Nurse Theorists

Appendix C. The Development of Essential Nursing Documents

A Timeline of Development

Appendix D. Position Statement: Professional Role Competence

Definitions and Concepts in Competence

Competence and Competency in Nursing Practice

Evaluating Competence

Recommendations/Next Steps

References

Index

Contributors

Nursing: Scope and Standards of Practice, Fourth Edition, is the product of extensive thought work by many registered nurses examining the American Nurses Association’s Nursing: Scope and Standards of Practice, Third Edition (2015b) followed by a three-step review process. This document originated from the multitude of decisions garnered during a significant number of video telephone conference calls and email communications of the diverse workgroup members in 2019–2020. The workgroup was always guided by Abe Lincoln’s quote, The best way to predict your future is to create it. The first review involved a 30-day public comment period. All workgroup members reviewed every submitted comment, resulting in further workgroup refinements of the draft document. The two following official American Nurses Association (ANA) review processes included evaluation by the Committee on Nursing Practice Standards in December 2020 and final review and approval by the ANA Board of Directors in January 2021.

NURSING SCOPE AND STANDARDS WORKGROUP, 2019–2020

Patricia J. Bartzak, DNP, RN, CMSRN, TCRN (Co-Chair)

Kahlil A. Demonbreun, DNP, RNC-OB, WHNP-BC, ANP-BC, FAANP, FAAN (Co-Chair)

Barbara A. Brunt, MA, MN, RN, NPD-BC, NE-BC, FABC

Carol Peyton Bryant, DNP, RN, ACNP, CCRN

Colleen Casper, DNP, MS, RN

Tracy K. Davidson, DNP, MPH, RN

Jessica L. Dzubak, MSN, RN

Carla A. Lee, PhD, EdS, MN, RN, APRN-BC, A/FNP, CNS, CHES, FIBA, FAAN

Kristy Nielson, DNP, RN, CCRN-K, CNE

Jennifer Pettis, MS, RN, CNE, WCC

Colleen L. Quesnell, DNP, RN, WHNP-BC, ANP-BC, CNM

Catherine Robichaux, PhD, RN, Alumna CCRN

Deborah Shields, PhD, RN, CCRN, QTTT, AHN-BC

Suzanne H. Sikes-Thurman, BSN, RN

Felicia D. Stewart, DNP, RN-BC, FNP-C

Deirdre Thornlow, PhD, RN, CPHQ

Linda L. Wagner, MA, RN, NE-BC

OTHERS

Lisa Herrington, MSN, BSN, RN-BC

Monica E. Kolbuk, MSN, RN, CEN

Joyce N. Morris, MSN, RN-BC

Jamie L. Sirman, MSN, RN-BC, CDE

ANA COMMITTEE ON NURSING PRACTICE STANDARDS—REVIEWERS

Mona Pearl Treyball, PhD, RN, CNS, CCRN-K, FAAN (Co-chair)

Stacy McNall, MSN, RN, IBCLC, PMPNP-BC (Co-chair)

Patricia Bowe, DNP, MS, RN

Nena M. Bonuel, PhD, RN, APRN-BC, ACNS-BC, CCRN-K

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

Elizabeth O. Dietz, EdD, RN, CS-NP, CSN

Kirk Koyama, MSN, RN, CNS, PHN

Tonette McAndrew, MPA, RN

Amy McCarthy, MSN, RN, RNC-MNN, NE-BC

Linda Inez Perkins, MSN, RN-BC

Verna Sitzer, PhD, RN, CNS

ANA STAFF

Carol J. Bickford, PhD, RN-BC, CPHIMS, FAMIA, FHIMSS, FAAN (content editor)

Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC (contributor)

Alison May, BS (graphics designer)

Erin Walpole, BA, PMP (production editor)

James Angelo, MA (publications manager)

ABOUT THE AMERICAN NURSES ASSOCIATION

The American Nurses Association (ANA) is the premier organization representing the interests of the nation’s 4.2 million registered nurses. ANA advances the profession by fostering high standards of nursing practice, promoting a safe and ethical work environment, bolstering the health and wellness of nurses, and advocating on healthcare issues that affect nurses and the public. ANA is at the forefront of improving the quality of health care for all.

ABOUT THE AMERICAN NURSES ASSOCIATION PUBLISHING PROGRAM

The American Nurses Association (nursingworld.org/nurses-books/) 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 foundational documents of the profession on nursing ethics, scope and standards of practice, and social policy, ANA is the publisher for the professional, career-oriented nurse, reaching and serving nurse educators, administrators, managers, and researchers during their professional development.

Scope of Nursing Practice

"Imagine a world without nurses. Think of a world without persons who know what nurses do;

who have the effect that nurses have on the health of individuals, families, and the nation;

who enjoy the trust that nurses enjoy from the American people.

Imagine a world like that, a world without nurses."

Margretta Gretta Madden Styles, EdD, RN, FAAN

DEFINITION OF NURSING

Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.

This revised definition presents reordering the content from the 2015 version (ANA, 2015b), including the art and science of caring, replacing abilities with human functioning, and incorporating references to compassionate presence and recognition of the connection of all humanity. Such refinements reflect an evolution of thinking over the past five years and present enhancements intended to lead into the future.

Formatting the definition as a bullet list provides an opportunity to further appreciate the richness and diversity of the integrated concepts:

Nursing:

Integrates the art and science of caring

Protects, promotes, and optimizes health and human functioning

Prevents illness and injury

Facilitates healing

Alleviates suffering through compassionate presence

Nursing is:

the diagnosis and treatment of human responses and

advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.

OTHER DEFINITIONS

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 nurses’ attention. Healthcare consumers receive nursing services as sanctioned by the state regulatory bodies. The more global term healthcare consumer is intended to reflect a proactive focus on health and wellness care, rather than a reaction to disease and illness.

Registered nurses (RN) are individuals who are educationally prepared and then licensed by a state, commonwealth, territory, or government regulatory body to practice as a registered nurse. Nurse and professional nurse are synonyms for a registered nurse in this document. Numerous jurisdictions have identified nurse as a protected title.

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 role; and are not required to have additional regulatory oversight.

Advanced practice registered nurses (APRN) are a subset of graduate-level prepared registered nurses who have completed an accredited graduate-level education program preparing the nurse for special licensure recognition and practice for one of the four recognized APRN roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), or certified nurse practitioner (CNP). APRNs assume responsibility and accountability for health promotion and/or maintenance, as well as the assessment, diagnosis, and management of healthcare consumer problems, which includes the use and prescription of pharmacologic and nonpharmacologic interventions (APRN Joint Dialogue Group, 2008). Some clinicians in this classification began APRN practice prior to the current educational preparation requirement and have been grandfathered to hold this designation.

DESCRIPTION OF THE SCOPE OF NURSING PRACTICE

The Scope of Nursing Practice describes the who, what, where, when, why, and how associated with nursing practice and roles. Each question must be answered to provide a complete picture of the dynamic and complex practice of nursing and its membership and evolving boundaries. The definition of nursing provides a succinct characterization of the what of nursing. All registered nurses, including those identified as graduate-level prepared nurses or advanced practice registered nurses, comprise the who constituency and have been educated, titled, and maintain active licensure to practice nursing. Nursing occurs when 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