Nursing practice has evolved over the centuries, beginning with Florence Nightingale in the 19th century conducting her own research on caring for soldiers in the Crimean War, to contemporary nursing practice in the 21st century where healthcare delivery has become complex, requiring a highly educated nursing workforce to meet the needs of a diverse, aging population.
This opening chapter on professional nursing practice begins with the definition of nursing. The American Nurses Association (ANA, 2015c) defines the concept of 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 (p. 1)
Nursing has been referred to as an art and a science since the early 20th century when nurse licensure laws were first enacted. The concepts art and science are considered the defining characteristics of nursing, thus helping nurses understand and explain the nature of nursing practice (Peplau, 1988).
In the mid-nineteenth century, the art of nursing was characterized as mothering and homemaking. A century later, the art of nursing was referred to as “nursing arts”, characterized as bathing, bedmaking, positioning patients, comforting techniques, and hospital housekeeping (. , 1981).
Peplau (1988) categorizes the art of nursing as “. . . enabling, empowering, or transforming art. It’s aim, among other goals, is to produce favorable changes within clients through nursing services” (p. 9). People are changed on a personal level as a result of the acts provided by nurses (Peplau, 1988). Creating trusting relationships with patients, and others, comes from the art of nursing, it gives nurses the opportunity to speak freely and honestly, to counsel and share their thoughts, knowledge, and feelings in a caring, genuine way.
Pagana (1987) suggests “. . . nurses are major keepers of the morality, goodness, honesty, ethics of client care, [often referred to as] a patient advocate” (p. 9). Expressions associated with the art of nursing includes “individualized care”, “uniqueness of the patient”, and “the patient as a person” (Peplau, 1988, p. 9). The art of nursing relies on nurses using common sense, reflection of client experiences, and personal observation (Peplau, 1988).
Today, the ANA (2015c) describes the art of nursing as the act of caring and respect for human dignity. Approaching care in a compassionate way brings about competent care. Embracing spirituality, healing, empathy, mutual respect and compassion promotes health and healing. Nurses express art through helping, listening, mentoring, coaching, touching, intuition, cultural competence, tolerance, acceptance, and nurturing.
Many of the attributes of the art of nursing are an inherent part of nursing practice, such as respect for human dignity and compassion. Though some nurses may need to learn some of these attributes through observation of others, such as touching and nurturing. Consider how the art of nursing can be taught in nursing school or learned/strengthened throughout one’s career.
A Caring Profession
Nursing is a caring profession, and those who enter the profession often do so for altruistic reasons. People are attracted to the profession because of their desire to help those in need, those who are vulnerable. Gormley (1996) writes “Altruism represents an amalgamation of intrinsic and extrinsic factors which either permit or coerce individuals to take responsibility for or care for another and to sacrifice things dearly held” (p. 581). When caring originates from a group of altruistic individuals, called collective altruism, such as a hospital unit, the generalized concern results in the success of the group’s goals and desires (Gormley, 1996).
Nursing theorists have studied the nature of caring and how it impacts both the patient and the nurse. Watson (1988) explains how nurses assist patients to find meaning in their illness by protecting them and preserving human dignity through caring moments. These caring moments lead patients to self-discovery and self-knowledge. For example, the act of holding a patient’s hand the night before surgery or listening to a grieving patient’s sorrow become long-lasting memories for both the patient and the nurse.
Up until the 1940s, the science of nursing was considered knowledge gleaned from science courses during nursing education. By the 1970s, the science of nursing was referred to as systematized knowledge and became a more significant component in nursing education (Peplau, 1988).
As time passed, nurses wanted to further the professionalization of nursing practice. In order for nursing to be considered a profession, science needed to become a more significant component of practice (Peplau, 1988). According to the ANA (1980), a profession must include the use of scientific knowledge to understand and treat phenomena. Through use of scientific inquiry, nurses use theory to investigate and explain phenomenon, determine interventions, and design a plan of care (ANA, 1980). The science of nursing explained the patterns and problems of human beings as a group (Peplau, 1988).
Today, a chief component of nursing practice includes application of evidence-based practice and research in the clinical setting, and scientific investigation. Nurses are actively involved in scientific research at academic institutions as well as the federal level. The National Institute of Nursing Research (NINR, n.d.) is a federally funded nursing research program with a focus on improving population health through scientific research in behavioral and biological sciences. Additional information on NINRs research programs can be found at the .
As a scientific discipline, nursing draws on knowledge from scientific research, nursing theory, the relationship between patients, nurses, and the environment within the context of health, theories from science, humanities, and other related disciplines.
The ANA has developed three foundational documents for registered nurses, listed below. These documents were written for all registered nurses and are used to inform their thinking and decision-making in nursing practice settings.
- Code of Ethics for Nurses with Interpretive Statements
- Nursing: Scope and Standards of Practice.
- Nursing’s Social Policy Statement: The Essence of the Profession
The Code of Ethics is an expression of the values, duties, and commitments of registered nurses. The first Code of Ethics was written in 1893 in the form of a pledge similar to the Hippocratic Oath and is now a living document that continually evolves in accordance with the changing social context of nursing (ANA, 2015a).
|Provision 1||Affirming health through relationships of dignity and respect
|Provision 2||The patient as nursing’s foundational commitment
|Provision 3||Advocacy’s geography
|Provision 4||The expectations of expertise
|Provision 5||The nurse as person of dignity and worth
|Provision 6||The moral milieu of nursing practice
|Provision 7||Diverse contributions to the profession
|Provision 8||Collaboration to reach for greater ends
|Provision 9||Social justice: Reaching out to a world in need of nursing
The ANA (2015c) Nursing: Scope and Standards of Practice contains the Scope of Nursing Practice and the Standards of Professional Nursing Practice. The latter is comprised of the Standards of Practice (standards 1-6) and the Standards of Professional Performance (standards 7-17).
Scope of Nursing Practice
The scope describes the activities performed by the nurse as the who, what, where, when, why, and how nursing is practiced (ANA, 2015c). Responses to these questions are answered “to provide a complete picture of the dynamic and complex practice of nursing” (ANA, 2015c, p. 2). The following describes how each of these questions are answered:
- Who: the registered nurse
- What: this is the definition of nursing, as listed above.
- Where: any place there is a need for care, advocacy, or knowledge
- When: anytime there is a need for nursing knowledge, wisdom, leadership, caring
- Why: nurses need to maintain the social contract with society, adapting care based on the changing needs of the society
- How: the method and manner to which nurses practice professionally (ANA, 2015c, p. 2)
Standards of Practice
The Standards of Practice describe a competent level of nursing care expected of all registered nurses, regardless of their role, specialty, or position. The depth and breadth of how nurses employ these practices are dependent upon level of education, self-development, experience, role, setting, and patient population being served (ANA, 2015b). These Standards are often referred to as the nursing process or the acronym ADPIE (assessment, diagnosis, planning, implementation and evaluation). Registered nurses are expected to demonstrate critical thinking throughout all actions taken during each standard, which forms the foundation for decision-making (ANA, 2015c). See Table 1 for the Standards of Practice.
Table 1 lists the 6 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, 2015c, pp. 56-66)|
Standards of Professional Performance
The Standards of Professional Performance describes competent behaviors of the professional registered nurse, depending on role, position, and level of education. Some standards may or may not be applicable to patient care. Registered nurses are expected to engage in professional activities related to their role, such as leadership, formal or informal, based upon level of education. Registered nurses are held accountable to themselves, the healthcare consumer, peers, employer, and society as they carry out the competencies of each standard (ANA, 2010). See Table 2 for the Standards of Professional Performance.
Table 2 lists the 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.
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 practice in an environmentally safe and healthy manner.
|(ANA, 2015c, pp. 67-84)|
Nursing’s social policy statement describes the value of the nursing profession within society, defines the concept of nursing, reviews the standards of practice, and regulation of nursing practice. The nursing practice is inherently connected to society, thus requiring a social contract between society and the profession (ANA, 2015b).
Nursing’s core values and ethics serve as a social contract to society, which provides a foundation for the health of society. Through licensure, affirmation, and legislation, society validates the need for and trust in nursing profession. The nursing profession meets society’s need to obtain healthcare, regardless of cultural, social, or economic standing (ANA, 2015b).
Since 2001, the Gallup poll found Americans ranked nurses as the most trustworthy, with the highest ethical standards compared to 21 other professions (Reinhart, 2020). The nursing profession is trusted by society to provide quality, ethical care. Society gives permission to the profession of nursing to work autonomously to meet the needs of society as a whole. In return, the nursing profession is expected to provide healthcare in a responsible manner while maintaining the public’s trust (Donabedian, 1976).
There are several important organizations and documents that have significant impact on practice, education, and professional growth. Below is a list of organizations and research reports that have are foundational to implementing practices that ensure high standards of care.
The American Nurses Association (ANA, n.d.-a) was founded in 1896 with the goal of advancing the nursing profession and improving the quality of care for all. Since its inception well over a century ago, membership is widespread throughout all 50 states and U.S. territories, and known as the “strongest voice of the profession”. The ANA advances the profession through the development many foundational documents, white papers, position statements, initiatives, among others:
- Standards of Practice and Performance for nursing including practice-focused standards for 25 nursing specialties
- Code of Ethics
- Social Policy Statement
- Advocacy efforts with health policy and safe working environments
- Research and funding opportunities
- Self-care for nurses
- Lobbying Congress
The ANA (n.d.-a) fights for what nurses need, what they believe in, and supports nurses to lead change in this ever-evolving healthcare environment. The ANA empowers nurses in the hopes of making positive changes in healthcare and fighting for what their patients need. Below are some of the efforts the ANA continues to work towards:
- Expanded roles for RNs and Advanced Practice Registered Nurses (APRN)
- Federal funding for nursing education and training
- Improvement of the healthcare environment
- Medicare reform
- Safe staffing
- Workplace violence
- Whistleblowing protection
The ANA (n.d.-b) has developed the following organizational platforms focused on nursing excellence:
- Magnet Recognition Program
- Pathway to Excellence
- American Nurses Credentialing Center
- ANA Enterprise
- American Nurses Foundation
- ANCC Accreditation
- ANA Certifications
The National League for Nursing (NLN, 2020) was founded in 1893 as the as the American Society of Superintendents of Training Schools for Nurses, the first U.S. professional nursing organization. The NLN is considered the premier organization for nursing education. Membership includes individual faculty members and leaders in nursing education including healthcare organizations and agencies. The organization offers its 40,000 individual members and 1200 institutional members a wide array of services and opportunities:
- Professional development
- Research and grant opportunities
- Testing services
- Recognition programs
- Certification for nurse educators
- Advocacy and public policy initiatives.
- Commission for Nursing Education Accreditation (CNEA) activities for associate, diploma, baccalaureate, and post-graduate degree nursing programs.
The American Association of Colleges of Nursing (AACN, 2020b) was founded in 1969 as the voice of academic nursing education. Some of the major activities of the AACN include establishment of quality standards for nursing education, assist nursing schools on how to be implement quality standards, and promote public support of nursing education, research, and practice. Membership includes 814 schools of nursing that offer baccalaureate, graduate, and post-graduate programs, 45,000 individual members, with 513,000 students. AACN (2020b) offers the following programs, foundational documents, and initiatives:
- Essentials of Baccalaureate Education for Professional Nursing Practice. To view the 2008 version of the Baccalaureate Education Essentials document, visit the and click “Previous Essentials Series”
- Position Statement: The Baccalaureate Degree in Nursing as Minimal Preparation for Professional Practice. To view the Position Statement, visit the .
- Curriculum standards: includes the Essentials documents, which outlines the competencies for graduates of baccalaureate, master’s, and Doctor of Nursing Practice (DNP) degrees
- Conferences and webinars
- Grant funding
- Policy and Advocacy
- Commission on Collegiate Nursing Education (CCNE) Accreditation activities for baccalaureate, graduate, and residency programs in nursing
- Journals, white papers, position statements, faculty tool kits, and more
The National Council of State Boards of Nursing (NCSBN, 2020b) was founded in 1978 as an independent, not-for-profit organization. NCSBN’s core goal is focused on ensuring safe patient care and protecting the public through implementation of unbiased regulation (NCSBN, 2020c). NCSBN membership consists of the following boards of nursing (BON):
- 50 U.S. states, including District of Columbia
- Four U.S. territories: American Samoa, Guam, Northern Mariana Islands, and the Virgin Islands
- Three states have two BONs; one for RNs and one for LPNs: California, Louisiana, and West Virginia
- Nebraska has the BON for RNs and the BON for advanced practice nurses (NCSBN, 2020a)
The NCSBN (2020b) is responsible for the following activities:
- Regulation of over 4.8 million nurses
- Developed the National Council Licensure Examination (NCLEX-RN and NCLEX-PN)
- Collaborative research
- Position papers
- Nursing disciplinary database
- Verification of nursing licensure
- Practice privileges
- Nurse Practice Act designed and published (see Accountability chapter for more information)
- Gathers national data on RNs, LPNs
- Publishes the Journal of Nursing Regulation
The Health and Medicine Division (HMD) (formerly the Institute of Medicine (IOM)) is part of the National Academies of Sciences, Engineering, and Medicine (NAS). The organization has been in operation since 1863. The NAS conducts research by request from federal agencies, independent organizations, or by Congressional mandate. The NAS is responsible for conducting objective research that is used to advise and inform public policy in relation to science, technology, and medicine. The overarching goal of HMD is to inform those working in both the government and the private sectors on how to make healthcare decisions by providing reliable, objective, and informative research findings (NAS, 2020).
The NAS conducts research on a variety of healthcare topics, including aging, health literacy, obesity, cancer, social determinants of health, among others. For more information about NAS research, visit the .
Previous to the naming of the NAS organization, the IOM published landmark reports on The Future of Nursing (listed below) which explore nursing roles, responsibilities, standards of practice, education, among other topics. These reports were conducted to meet the needs of a diverse, aging, and complex healthcare environment.
- To view the report on the Future of Nursing: Leading Change, Advancing Health, download the PDF file in week 1.
Brown (1992) explains the origins of the concept profession from 1675. The concept was first used in secular society with the following definition: “… to define, organize, and publicize their own particular expertise and cultural authority (p. 18)”. Many occupations today have similarities with this definition. Consider the professions of nursing, lawyers, and accountants requiring a particular expertise. They are all organized entities, publicized to those who are in need of such expertise, and they subscribe to a particular culture or way of being.
Today, scholars have defined particular characteristics of a profession in order to differentiate from an occupation. Buhai (2012) lists the following characteristics of a profession:
- specialized training/education
- autonomy of practice
- ethical practice
- expert knowledge
- continuing education
- service to society
Nursing has been referred to as a profession for many years, meeting all of the above characteristics, though its status as a profession has been debated. One of the characteristics of a profession under debate is the educational requirement, entry level to practice. Nursing offers multiple pathways to practice, including diploma, associate, and baccalaureate. Each program of study varies widely with depth and breadth of nursing content, though each graduate takes the same licensure exam (Krugman & Goode, 2018).
By the early 21st century, disciplines within the healthcare field have increased minimum preparation for practice to higher levels of education, including physical therapy (master’s degree or doctorate) and pharmacy (doctorate) (Krugman & Goode, 2018). Since nursing does not have a clear pathway to practice (Blais & Hayes, 2011; Krugman & Goode, 2018) it has been argued that nursing has still not met the educational requirement of a profession (Joel & Kelly, 2002). Until the entry to practice issue is resolved, some may not consider nursing as a true profession.
The ANA (2015c) lists five core tenets of nursing practice, all of which are weaved throughout the 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, 2012).
2. Nursing practice is individualized
Respect for human dignity and diversity is at the core of identifying and meeting the unique needs of the healthcare consumer or situation (ANA, 2015c, p. 8).
3. Registered nurses use the nursing process to plan and provide individualized care for healthcare consumers
Nurses apply the six standards of practice during encounters with the healthcare consumer, groups, or populations. The use of theory and evidence-based knowledge is used to collaborate with the healthcare consumer [or others] to achieve the best outcomes (ANA, 2015c, p. 8).
4. Nurses coordinate care by establishing partnerships
Partnerships with persons, families, groups, support systems, and other stakeholders should be established using multiple forms of communication. Share goal-setting should include delivery of safe, quality care (ANA, 2015c, p. 8).
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
Nurses have an ethical obligation to create healthy practice environments that are conducive to provision of quality healthcare (ANA, 2015c, p. 9)
See chapter 4, Leadership in Nursing, for more information about healthy working environments
The ANA (2014) published a Position Statement on Professional Role Competence for all registered nurses. The following summarizes the main points of the Position Statement, outlining the expectations of society, nurses, the profession, and employers:
- The public has a right to expect all nurses demonstrate competence in their role throughout their career
- Nurses are responsible and accountable for maintaining role competence
- The nursing profession and regulatory agencies verify the processes for measuring competence is appropriate, and they meet the minimum standards to protect the general public
- Employers are responsible and accountable for providing a safe working environment conducive to competent practice
Massachusetts Department of Higher Education Nursing (2016) created the Nurse of the Future competencies for professional nursing practice:
- Patient-Centered Care
Provision of “holistic care that recognizes an individual’s preferences, values, and needs and respects the patient or designee as a full partner in providing compassionate, coordinated, age and culturally appropriate, safe and effective care” (p. 10)
“Accountability for the delivery of standard-based nursing care that is consistent with moral, altruistic, legal, ethical, regulatory, and humanistic principles” (p. 14)
“Influence the behavior of individuals or groups of individuals within their environment in a way that will facilitate the establishment and acquisition/achievement of shared goals” (p. 18)\
see Chapter 4 for more information on nursing leadership
- Informatics and Technology
“Use advanced technology and to analyze as well as synthesize information and collaborate in order to make critical decisions that optimize patient outcomes” (p. 26)
- Evidenced-Based Practice
“Identify, evaluate, and use the best current evidence coupled with clinical expertise and consideration of patients’ preferences, experience and values to make practice decisions” (p. 47)
see Chapter 3 for more information on evidence-based practice
- Systems-Based Practice
“Awareness of and responsiveness to the larger context of the health care system, and will demonstrate the ability to effectively call on work unit resources to provide care that is of optimal quality and value” (p. 20)
“Minimize risk of harm to patients and providers through both system effectiveness and individual performance” (p. 42)
“interact effectively with patients, families, and colleagues, fostering mutual respect and shared decision making, to enhance patient satisfaction and health outcomes” (p. 32)
see Chapter 3 for more information on communication
- Teamwork and Collaboration
“Function effectively within nursing and interdisciplinary teams, fostering open communication, mutual respect, shared decision making, team learning, and development” (p. 37)
see Chapter 3 for more information on teamwork and collaboration
- Quality Improvement
“Use data to monitor the outcomes of care processes, and uses improvement methods to design and test changes to continuously improve the quality and safety of health care systems” (p. 45)