American Nurses Association

American Nurses Association. (2015). Nursing: Scope and standards of Practice (3rd. ed). Silver Spring, MD. 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. P.2 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 P.3 midwife (CNM), clinical nurse specialist (CNS), or certified nurse practitioner (CNP)]; Who have passed a national certification examination that measures APRN-, role-, and population-focused competencies and maintain continued competence as evidenced by recertification in the role and population through the national certification program; Who have acquired advanced clinical knowledge and skills 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. P.4 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. P.5 Standard 6. Evaluation The registered nurse evaluates progress toward attainment of goals and outcomes. Standards of Professional Performance The Standards of Professional Performance describe a competent level of behavior in the professional role, including activities related to ethics, 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. P.6 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 P.7 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. 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” P.8 (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). 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. 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. 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. P.9 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 P.10 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. P.11 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 P.12 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, P.13 individually and collectively, serving as the vanguard of society's human caring needs now and in the future. If nursing does not fulfill its societal mandate for sustaining human caring, preserving human dignity and humanness in self, systems, and society, it will not be carrying out its covenant to humankind and its reason for existence as a profession. (Watson, 2012, p. 42) Cultural Components of Care Leininger (1988) considered care for people from a broad range of cultures and contributed to the unique body of nursing knowledge by translating and integrating transcultural precepts from the field of anthropology into 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. P.14 FIGURE 1. The Nursing Process and the Standards of Professional Nusing Practice P.15 The Standards of Practice These standards describe a competent level of nursing practice demonstrated by the critical thinking model known as the nursing process; its six components correspond to these standards. Standard Nursing Process Component Standard 1 Assessment Standard 2 Diagnosis Standard 3 Outcomes Identification Standard 4 Planning Standard 5 Implementation Standard 6 Evaluation The Standards of Professional Performance These standards describe a competent level of behavior in the professional role appropriate to their education and position. Standard Professional Performance Standard 7 Ethics Standard 8 Culturally Congruent Practice Standard 9 Communication Standard 10 Collaboration Standard 11 Leadership Standard 12 Education Standard 13 Evidence-based Practice and Research Standard 14 Quality of Practice Standard 15 Professional Practice Evaluation Standard 16 Resource Utilization Standard 17 Environmental Health 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 P.30 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 P.31 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)] P.32 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 P.33 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). Standards of Practice Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation. Competencies The registered nurse: ? Collects pertinent data, including but not limited to demographics, social determinants of health, health disparities, and physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic assessments in a systematic, ongoing process with compassion and respect for the inherent dignity, worth, and unique attributes of every person. ? Recognizes the importance of the assessment parameters identified by WHO (World Health Organization), Healthy People 2020, or other organizations that influence nursing practice. ? Integrates knowledge from global and environmental factors into the assessment process. ? Elicits the healthcare consumer's values, preferences, expressed and unexpressed needs, and knowledge of the healthcare situation. ? Recognizes the impact of one's own personal attitudes, values, and beliefs on the assessment process. ? Identifies barriers to effective communication based on psychosocial, literacy, financial, and cultural considerations. ? Assesses the impact of family dynamics on healthcare consumer health and wellness. P.54 ? Engages the healthcare consumer and other interprofessional team members in holistic, culturally sensitive data collection. ? Prioritizes data collection based on the healthcare consumer's immediate condition or the anticipated needs of the healthcare consumer or situation. ? Uses evidence-based assessment techniques, instruments, tools, available data, information, and knowledge relevant to the situation to identify patterns and variances. ? Applies ethical, legal, and privacy guidelines and policies to the collection, maintenance, use, and dissemination of data and information. ? Recognizes the healthcare consumer as the authority on their own health by honoring their care preferences. ? Documents relevant data accurately and in a manner accessible to the interprofessional team. Additional competencies for the graduate-level prepared registered nurse In addition to the registered nurse competencies, the graduate-level prepared registered nurse and the advanced practice registered nurse: ? Assesses the effect of interactions among individuals, family, community, and social systems on health and illness. ? Synthesizes the results and information leading to clinical understanding. Additional competencies for the advanced practice registered nurse In addition to the competencies of the registered nurse and the graduate-level prepared registered nurse, the advanced practice registered nurse: ? Initiates diagnostic tests and procedures relevant to the healthcare consumer's current status. ? Uses advanced assessment, knowledge, and skills to maintain, enhance, or improve health conditions. P.55 Standard 2. Diagnosis The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues. Competencies The registered nurse: ? Identifies actual or potential risks to the healthcare consumer's health and safety or barriers to health, which may include but are not limited to interpersonal, systematic, cultural, or environmental circumstances. ? Uses assessment data, standardized classification systems, technology, and clinical decision support tools to articulate actual or potential diagnoses, problems, and issues. ? Verifies the diagnoses, problems, and issues with the individual, family, group, community, population, and interprofessional colleagues. ? Prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the healthcare consumer across the health-illness continuum. ? Documents diagnoses, problems, and issues in a manner that facilitates the determination of the expected outcomes and plan. Additional competencies for the graduate-level prepared registered nurse In addition to the competencies of the registered nurse, the graduate-level prepared registered nurse: ? Uses information and communication technologies to analyze diagnostic practice patterns of nurses and other members of the interprofessional healthcare team. ? Employs aggregate-level data to articulate diagnoses, problems, and issues of healthcare consumers and organizational systems. P.56 Additional competencies for the advanced practice registered nurse In addition to the competencies of the registered nurse and the graduate-level prepared registered nurse, the advanced practice registered nurse: ? Formulates a differential diagnosis based on the assessment, history, physical examination, and diagnostic test results. P.57 Standard 3. Outcomes Identification The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation. Competencies The registered nurse: ? Engages the healthcare consumer, interprofessional team, and others in partnership to identify expected outcomes. ? Formulates culturally sensitive expected outcomes derived from assessments and diagnoses. ? Uses clinical expertise and current evidence-based practice to identify health risks, benefits, costs, and/or expected trajectory of the condition. ? Collaborates with the healthcare consumer to define expected outcomes integrating the healthcare consumer's culture, values, and ethical considerations. ? Generates a time frame for the attainment of expected outcomes. ? Develops expected outcomes that facilitate coordination of care. ? Modifies expected outcomes based on the evaluation of the status of the healthcare consumer and situation. ? Documents expected outcomes as measurable goals. ? Evaluates the actual outcomes in relation to expected outcomes, safety, and quality standards. Additional competencies for the graduate-level prepared registered nurse, including the APRN In addition to the competencies of the registered nurse, the graduate-level prepared registered nurse or advanced practice registered nurse: ? Defines expected outcomes that incorporate cost, clinical effectiveness, and are aligned with the outcomes identified by members of the interprofessional team. ? Differentiates outcomes that require care process interventions from those that require system-level actions. ? Integrates scientific evidence and best practices to achieve expected outcomes. P.58 ? Advocates for outcomes that reflect the healthcare consumer's culture, values, and ethical concerns. P.59 Standard 4. Planning The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes. Competencies The registered nurse: ? Develops an individualized, holistic, evidence-based plan in partnership with the healthcare consumer and interprofessional team. ? Establishes the plan priorities with the healthcare consumer and interprofessional team. ? Advocates for responsible and appropriate use of interventions to minimize unwarranted or unwanted treatment and/or healthcare consumer suffering. ? Prioritizes elements of the plan based on the assessment of the healthcare consumer's level of risk and safety needs. ? Includes evidence-based strategies in the plan to address each of the identified diagnoses, problems, or issues. These strategies may include but are not limited to: ? Promotion and restoration of health, ? Prevention of illness, injury, and disease, ? Facilitation of healing, ? Alleviation of suffering, and ? Supportive care ? Incorporates an implementation pathway that describes steps and milestones. ? Identifies cost and economic implications of the plan. ? Develops a plan that reflects compliance with current statutes, rules and regulations, and standards. ? Modifies the plan according to the ongoing assessment of the healthcare consumer's response and other outcome indicators. ? Documents the plan using standardized language or recognized terminology. P.60 Additional competencies for the graduate-level prepared registered nurse In addition to the competencies of the registered nurse, the graduate-level prepared registered nurse: ? Designs strategies and tactics to meet the multifaceted and complex needs of healthcare consumers or others. ? Leads the design and development of interprofessional processes to address the identified diagnoses, problems, or issues. ? Designs innovative nursing practices. ? Actively participates in the development and continuous improvement of systems that support the planning process. Additional competencies for the advanced practice registered nurse In addition to the competencies of the registered nurse and graduate-level prepared registered nurse, the advanced practice registered nurse: ? Integrates assessment strategies, diagnostic strategies, and therapeutic interventions that reflect current evidence-based knowledge and practice. P.61 Standard 5. Implementation The registered nurse implements the identified plan. Competencies The registered nurse: ? Partners with the healthcare consumer to implement the plan in a safe, effective, efficient, timely, patient-centered, and equitable manner (IOM, 2010). ? Integrates interprofessional team partners in implementation of the plan through collaboration and communication across the continuum of care. ? Demonstrates caring behaviors to develop therapeutic relationships. ? Provides culturally congruent, holistic care that focuses on the healthcare consumer and addresses and advocates for the needs of diverse populations across the lifespan. ? Uses evidence-based interventions and strategies to achieve the mutually identified goals and outcomes specific to the problem or needs. ? Integrates critical thinking and technology solutions to implement the nursing process to collect, measure, record, retrieve, trend, and analyze data and information to enhance nursing practice and healthcare consumer outcomes. ? Delegates according to the health, safety, and welfare of the healthcare consumer and considering the circumstance, person, task, direction or communication, supervision, evaluation, as well as the state nurse practice act regulations, institution, and regulatory entities while maintaining accountability for the care. ? Documents implementation and any modifications, including changes or omissions, of the identified plan. Additional competencies for the graduate-level prepared registered nurse In addition to the competencies of the registered nurse, the graduate-level prepared registered nurse: ? Uses systems, organizations, and community resources to lead effective change and implement the plan. P.62 ? Applies quality principles while articulating methods, tools, performance measures, and standards as they relate to implementation of the plan. ? Translates evidence into practice. ? Leads interprofessional teams to communicate, collaborate, and consult effectively. ? Demonstrates leadership skills that emphasize ethical and critical decision-making, effective working relationships, and a systems perspective. ? Serves as a consultant to provide additional insight and potential solutions. ? Uses theory-driven approaches to effect organizational or system change. Additional competencies for the advanced practice registered nurse In addition to the competencies of the registered nurse and graduate-level prepared registered nurse, the advanced practice registered nurse: ? Uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations. ? Prescribes traditional and integrative evidence-based treatments, therapies, and procedures that are compatible with the healthcare consumer's cultural preferences and norms. ? Prescribes evidence-based pharmacological agents and treatments according to clinical indicators and results of diagnostic and laboratory tests. ? Provides clinical consultation for healthcare consumers and professionals related to complex clinical cases to improve care and patient outcomes. P.63 Standard 5A. Coordination of Care The registered nurse coordinates care delivery. Competencies The registered nurse: ? Organizes the components of the plan. ? Collaborates with the consumer to help manage health care based on mutually agreed upon outcomes. ? Manages a healthcare consumer's care in order to reach mutually agreed upon outcomes. ? Engages healthcare consumers in self-care to achieve preferred goals for quality of life. ? Assists the healthcare consumer to identify options for care. ? Communicates with the healthcare consumer, interprofessional team, and community-based resources to effect safe transitions in continuity of care. ? Advocates for the delivery of dignified and holistic care by the interprofessional team. ? Documents the coordination of care. Additional competencies for the graduate-level prepared registered nurse In addition to the competencies of the registered nurse, the graduate-level prepared registered nurse: ? Provides leadership in the coordination of interprofessional health care for integrated delivery of healthcare consumer services to achieve safe, effective, efficient, timely, patient-centered, and equitable care (IOM, 2010). P.64 Additional competencies for the advanced practice registered nurse In addition to the competencies of the registered nurse and graduate-level prepared registered nurse, the advanced practice registered nurse: ? Manages identified consumer panels or populations. ? Serves as the healthcare consumer's primary care provider and coordinator of healthcare services in accordance with state and federal laws and regulations. ? Synthesizes data and information to prescribe and provide necessary system and community support measures, including modifications of environments. P.65 Standard 5B. Health Teaching and Health Promotion The registered nurse employs strategies to promote health and a safe environment. Competencies The registered nurse: ? Provides opportunities for the healthcare consumer to identify needed healthcare promotion, disease prevention, and self-management topics. ? Uses health promotion and health teaching methods in collaboration with the healthcare consumer's values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status. ? Uses feedback and evaluations from the healthcare consumer to determine the effectiveness of the employed strategies. ? Uses technologies to communicate health promotion and disease prevention information to the healthcare consumer. ? Provides healthcare consumers with information about intended effects and potential adverse effects of the plan of care. ? Engages consumer alliance and advocacy groups in health teaching and health promotion activities for healthcare consumers. ? Provides anticipatory guidance to healthcare consumers to promote health and prevent or reduce the risk of negative health outcomes. Additional competencies for the graduate-level prepared registered nurse, including the APRN In addition to the competencies of the registered nurse, the graduate-level prepared registered nurse or advanced practice registered nurse: ? Synthesizes empirical evidence on risk behaviors, gender roles, learning theories, behavioral change theories, motivational theories, translational theories for evidence-based practice, epidemiology, and other related theories and frameworks when designing health education information and programs. ? Evaluates health information resources for applicability, accuracy, readability, and comprehensibility to help healthcare consumers access quality health information. P.66 Standard 6. Evaluation The registered nurse evaluates progress toward attainment of goals and outcomes. Competencies The registered nurse: ? Conducts a holistic, systematic, ongoing, and criterion-based evaluation of the goals and outcomes in relation to the structure, processes, and timeline prescribed in the plan. ? Collaborates with the healthcare consumer and others involved in the care or situation in the evaluation process. ? Determines, in partnership with the healthcare consumer and other stakeholders, the patient-centeredness, effectiveness, efficiency, safety, timeliness, and equitability (IOM, 2001) of the strategies in relation to the responses to the plan and attainment of outcomes. Other defined criteria (e.g., Quality and Safety Education for Nurses) may be used as well. ? Uses ongoing assessment data to revise the diagnoses, outcomes, plan, and implementation strategies. ? Shares evaluation data and conclusions with the healthcare consumer and other stakeholders in accordance with federal and state regulations. ? Documents the results of the evaluation. Additional competencies for the graduate-level prepared registered nurse, including the APRN In addition to the competencies of the registered nurse, the graduate-level prepared registered nurse or the advanced practice registered nurse: ? Synthesizes evaluation data from the healthcare consumer, community, population and/or institution to determine the effectiveness of the plan. ? Engages in a systematic evaluation process to revise the plan to enhance its effectiveness. ? Uses results of the evaluation to make or recommend process, policy, procedure, or protocol revisions when warranted. Standard 8. Culturally Congruent Practice The registered nurse practices in a manner that is congruent with cultural diversity and inclusion principles. Competencies The registered nurse: ? Demonstrates respect, equity, and empathy in actions and interactions with all healthcare consumers. ? Participates in life-long learning to understand cultural preferences, worldview, choices, and decision-making processes of diverse consumers. ? Creates an inventory of one's own values, beliefs, and cultural heritage. ? Applies knowledge of variations in health beliefs, practices, and communication patterns in all nursing practice activities. ? Identifies the stage of the consumer's acculturation and accompanying patterns of needs and engagement. ? Considers the effects and impact of discrimination and oppression on practice within and among vulnerable cultural groups. ? Uses skills and tools that are appropriately vetted for the culture, literacy, and language of the population served. ? Communicates with appropriate language and behaviors, including the use of medical interpreters and translators in accordance with consumer preferences. ? Identifies the cultural-specific meaning of interactions, terms, and content. ? Respects consumer decisions based on age, tradition, belief and family influence, and stage of acculturation. ? Advocates for policies that promote health and prevent harm among culturally diverse, under-served, or under-represented consumers. ? Promotes equal access to services, tests, interventions, health promotion programs, enrollment in research, education, and other opportunities. P.70 ? Educates nurse colleagues and other professionals about cultural similarities and differences of healthcare consumers, families, groups, communities, and populations. Additional competencies for the graduate-level prepared registered nurse In addition to the competencies of the registered nurse, the graduate-level prepared registered nurse: ? Evaluates tools, instruments, and services provided to culturally diverse populations. ? Advances organizational policies, programs, services, and practice that reflect respect, equity, and values for diversity and inclusion. ? Engages consumers, key stakeholders, and others in designing and establishing internal and external cross-cultural partnerships. ? Conducts research to improve health care and healthcare outcomes for culturally diverse consumers. ? Develops recruitment and retention strategies to achieve a multicultural workforce. Additional competencies for the advanced practice registered nurse In addition to the competencies of the registered nurse and graduate-level prepared registered nurse, the advanced practice registered nurse: ? Promotes shared decision-making solutions in planning, prescribing, and evaluating processes when the healthcare consumer's cultural preferences and norms may create incompatibility with evidence-based practice. ? Leads interprofessional teams to identify the cultural and language needs of the consumer. Standard 9. Communication The registered nurse communicates effectively in all areas of practice. Competencies The registered nurse: ? Assesses one's own communication skills and effectiveness. ? Demonstrates cultural empathy when communicating. ? Assesses communication ability, health literacy, resources, and preferences of healthcare consumers to inform the interprofessional team and others. ? Uses language translation resources to ensure effective communication. ? Incorporates appropriate alternative strategies to communicate effectively with healthcare consumers who have visual, speech, language, or communication difficulties. ? Uses communication styles and methods that demonstrate caring, respect, deep listening, authenticity, and trust. ? Conveys accurate information. ? Maintains communication with interprofessional team and others to facilitate safe transitions and continuity in care delivery. ? Contributes the nursing perspective in interactions with others and discussions with the interprofessional team. ? Exposes care processes and decisions when they do not appear to be in the best interest of the healthcare consumer. ? Discloses concerns related to potential or actual hazards and errors in care or the practice environment to the appropriate level. ? Demonstrates continuous improvement of communication skills. P.72 Additional competencies for the graduate-level prepared registered nurse, including the APRN In addition to the competencies of the registered nurse, the graduate-level prepared registered nurse or advanced practice registered nurse: ? Assumes a leadership role in shaping or fashioning environments that promote healthy communication.