Chapter 1 Scope of Practice (2024)

1.1. SCOPE OF PRACTICE INTRODUCTION

Learning Objectives

Discuss nursing scope of practice and standards of care
Compare various settings in which nurses work
Describe contributions of interprofessional health care team members
Describe levels of nursing education and the NCLEX
Discuss basic legal considerations and ethics
Outline professional nursing organizations
Examine quality and evidence-based practice in nursing

You are probably wondering, “What is scope of practice? What does it mean for me and my nursing practice?”Scope of practiceis defined as services that a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their professional nursing license. [1]Nursing scope of practice provides a framework and structured guidance for activities one can perform based on their nursing license. As a nurse and a nursing student, is always important to consider: Just because your employer asks you to do a task…can you perform this task according to your scope of practice – or are you putting your nursing license at risk?

Nurses must also follow legal standards in when providing nursing care. Standards are set by several organizations, including the American Nurses Association (ANA), your state’s Nurse Practice Act, agency policies and procedures, and federal regulators. These standards assure safe, competent care is provided to the public.

This chapter will provide an overview of basic concepts related to nursing scope of practice and standards of care.

References

1.: American Nurses Association. (n.d.).Scope of practice.https://www.nursingworld.org/practice-policy/scope-of-practice/↵.

1.2. HISTORY AND FOUNDATION

Brief History of Nursing

Before discussing scope and standards of nursing care, it is helpful to briefly review a history of the nursing profession. Florence Nightingale is considered to be the founder of modern nursing practice. In 1860 she established the first nursing school in the world. By establishing this school of nursing, Nightingale promoted the concept of nurses as a professional, educated workforce of caregivers for the sick. [1] See Figure 1.1 [2]for a portrait of Florence Nightingale. Florence Nightingale’s contributions to health care started during the Crimean War in 1854. Her team discovered that poor health care for wounded soldiers was being delivered by overworked medical staff in a dirty environment. Florence recorded the mortality rate in the hospital and created statistical models that demonstrated that out of every 1,000 injured soldiers, 600 were dying because of preventable communicable and infectious diseases. Florence’s nursing interventions were simple; she focused on providing a clean environment, clean water, and good nutrition to promote healing, such as providing fruit as part of the care for the wounded soldiers. With these simple actions, the mortality rate of the soldiers decreased from 60% to 2.2%. In 1859 Nightingale wrote a book titledNotes on Nursingthat served as the cornerstone of the Nightingale School of Nursing curriculum. Nightingale believed in the importance of placing a patient in a environment that promoted healing where they could recover from disease. She promoted this knowledge as distinct from medical knowledge. Her emphasis on the value of the environment formed many of the foundational principles that we still use in creating a healing health care setting today. She also insisted on the importance of building trusting relationships with patients and believed in the therapeutic healing that resulted from nurses’ presence with patients. She promoted the concept of confidentiality, stating a nurse “should never answer questions about her sick except to those who have a right to ask them.” [3]These nursing concepts formed the foundation of nursing practice as we know it today.

Figure 1.1

Florence Nightingale

Modern nursing has reinvented itself a number of times as health care has advanced and changed over the past 160 years. With more than four million members, the nursing profession represents the largest segment of the United States’ health care workforce. Nursing practice covers a broad continuum, including health promotion, disease prevention, coordination of care, and palliative care when cure is not possible. Nurses directly affect patient care and provide the majority of patient assessments, evaluations, and care in hospitals, nursing homes, clinics, schools, workplaces, and ambulatory settings. They are at the front lines in ensuring that patient care is delivered safely, effectively, and compassionately. Additionally, nurses attend to patients and their families in a holistic way that often goes beyond physical health needs and recognize social, mental, emotional, and spiritual needs. [4]

American Nurses Association (ANA)

The American Nurses Association (ANA) is a national, professional nursing organization that was established in 1896. The ANA represents the interests of nurses in all 50 states of America while also promoting improved health care for everyone. The mission of the ANA is to “lead the profession to shape the future of nursing and health care.” [5]The ANA states that it exists to advance the nursing profession by doing the following:

Fostering high standards of nursing practice
Promoting a safe and ethical work environment
Bolstering the health and wellness of nurses
Advocating on health care issues that affect nurses and the public [6]

The ANA sets many standard of care for professional nurses that will be discussed in the next section.

View theDiscover the American Nurses Associationvideo. [7]

References

1.: Karimi H., Masoudi Alavi N. Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies. 2015;4(2):e29475. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557413/ ↵ [PMC free article: PMC4557413] [PubMed: 26339672]
2.: “Florence Nightingale (H Hering NPG x82368).jpg” by Henry Hering (1814-1893) is in thePublic Domain↵.
3.: Karimi H., Masoudi Alavi N. Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies. 2015;4(2):e29475. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557413/ ↵ [PMC free article: PMC4557413] [PubMed: 26339672]
4.: Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2011).The future of nursing: Leading change, advancing health.National Academies Press.https://www.ncbi.nlm.nih.gov/books/NBK209880/57413/↵. [PubMed: 24983041]
5.: American Nurses Association. (n.d.).About ANA.https://www.nursingworld.org/ana/about-ana/↵.
6.: American Nurses Association. (n.d.).About ANA.https://www.nursingworld.org/ana/about-ana/↵.
7.: American Nurses Association. (2010, May 14).Discover the American Nurses Association (ANA). [Video]. YouTube. All rights reserved.https://youtu.be/PRwPhOjeqL4↵.

1.3. REGULATIONS & STANDARDS

Standards for nursing care are set by several organizations, including the American Nurses Association (ANA), your state’s Nurse Practice Act, agency policies and procedures, federal regulators, and other professional nursing organizations. These standards assure safe, competent care is provided to the public.

ANA Scope and Standards of Practice

The American Nurses Association (ANA) publishes two resources that set standards and guide professional nursing practice in the United States:The Code of Ethics for NursesandNursing: Scope and Standards of Practice. TheCode of Ethics for Nursesestablishes an ethical framework for nursing practice across all roles, levels, and settings. It is discussed in greater detail in the “Legal Considerations and Ethics” subsection of this chapter. TheNursing:Scope and Standards of Practicedescribes a professional nurse’s scope of practice and defines the who, what, where, when, why, and how of nursing. It also sets 18 standards of professional practice that all registered nurses are expected to perform competently. [1]

The “who” of nursing practice are the nurses who have been educated, titled, and maintain active licensure to practice nursing. The “what” ofnursingis the recently revised 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.” [2]Simply put, nurses treat human responses to health problems and life processes and advocate for the care of others.

Nursing practice occurs “when” there is a need for nursing knowledge, wisdom, caring, leadership, practice, or education, anytime, anywhere. Nursing practice occurs in any environment “where” there is a health care consumer in need of care, information, or advocacy. The “why” of nursing practice is described as nursing’s response to the changing needs of society to achieve positive health care consumer outcomes in keeping with nursing’s social contract and obligation to society. The “how” of nursing practice is defined as the ways, means, methods, and manners that nurses use to practice professionally. [3]The “how” of nursing is further defined by the standards of practice set by the ANA. There are two sets of standards, theStandards of Professional Nursing Practiceand theStandards of Professional Performance.

TheStandards of Professional Nursing Practiceare “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.” [4]These standards define a competent level of nursing practice based on the critical thinking model known as the nursing process. The nursing process includes the components ofassessment, diagnosis, outcomes identification, planning, implementation,andevaluation. [5]Each of these standards is further discussed in the “Nursing Process” chapter of this book.

TheStandards of Professional Performanceare 12 additional standards that describe a nurse’s professional behavior, including activities related to ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship, and environmental health. All registered nurses are expected to engage in these professional role activities based on their level of education, position, and role. Registered nurses are accountable for their professional behaviors to themselves, health care consumers, peers, and ultimately to society. [6]The 2021 Standards of Professional Performance are as follows:

Ethics.The registered nurse integrates ethics in all aspects of practice.
Advocacy.The registered nurse demonstrates advocacy in all roles and settings.
Respectful and Equitable Practice.The registered nurse practices with cultural humility and inclusiveness.
Communication.The registered nurse communicates effectively in all areas of professional practice.
Collaboration.The registered nurse collaborates with the health care consumer and other key stakeholders.
Leadership.The registered nurse leads within the profession and practice setting.
Education.The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking.
Scholarly Inquiry.The registered nurse integrates scholarship, evidence, and research findings into practice.
Quality of Practice.The registered nurse contributes to quality nursing practice.
Professional Practice Evaluation.The registered nurse evaluates one’s own and others’ nursing practice.
Resource Stewardship.The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and judiciously used.
Environmental Health.The registered nurse practices in a manner that advances environmental safety and health. [7]

Years ago, nurses were required to recite the Nightingale pledge to publicly confirm their commitment to maintain the profession’s high ethical and moral values: “I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and family affairs coming to my knowledge in the practice of my calling, with loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.” Although some of the words are outdated, the meaning is clear: Nursing is a calling, not just a job; to answer that call, you must be dedicated to serve your community according to the ANA standards of care and code of ethics. [8]

Nurse Practice Act

In addition to the professional standards of practice and professional performance set by the American Nurses Association, nurses must legally follow regulations set by the Nurse Practice Act and enforced by theBoard of Nursingin the state where they are employed. The Board of Nursing is the state-specific licensing and regulatory body that sets standards for safe nursing care and issues nursing licenses to qualified candidates, based on theNurse Practice Actenacted by that state’s legislature. The Nurse Practice Act establishes regulations for nursing practice within that state and defines the scope of nursing practice. If nurses do not follow the standards and scope of practice set forth by the Nurse Practice Act, they can have their nursing license revoked by the Board of Nursing.

To read more about the the Wisconsin Board of Nursing, Standards of Practice, and Rules of Conduct, use the hyperlinked PDFs provided below. [9]

Read about Wisconsin Standards of Practice for Nurses inChapter N 6.

Read about Wisconsin Rules of Conduct inChapter N 7.

Nursing students must understand their scope of practice outlined in their state’s Nurse Practice Act. Nursing students are legally accountable for the quality of care they provide to patients just as nurses are accountable. Students are expected to recognize the limits of their knowledge and experience and appropriately alert individuals in authority regarding situations that are beyond their competency. A violation of the standards of practice constitutes unprofessional conduct and can result in the Board of Nursing denying a license to a nursing graduate.

Employer Policies, Procedures, and Protocols

In addition to professional nursing standards set by the American Nurses Association and the state Nurse Practice Act where they work, nurses and nursing students must also practice according to agency policies, procedures, and protocols. For example, hospitals often set a policy that requires a thorough skin assessment must be completed and documented daily on every patient. If a nurse did not follow this policy and a patient developed a pressure injury, the nurse could be held liable. In addition, every agency has their own set of procedures and protocols that a nurse and nursing student must follow. For example, each agency has specific procedural steps for performing nursing skills, such as inserting urinary catheters. Aprotocolis defined by the Wisconsin Nurse Practice Act as a “precise and detailed written plan for a regimen of therapy.” For example, agencies typically have a hypoglycemia protocol that nurses automatically implement when a patient’s blood sugar falls below a specific number. The hypoglycemia protocol includes actions such as providing orange juice and rechecking the blood sugar. These agency-specific policies, procedures, and protocols supersede the information taught in nursing school, and nurses and nursing students can be held legally liable if they don’t follow them. Therefore, it is vital for nurses and nursing students to always review and follow current agency-specific procedures, policies, and protocols when providing patient care.

Nurses and nursing students must continue to follow their scope of practice as defined by the Nurse Practice Act in the state they are practicing when following agency policies, procedures, and protocols. Situations have occurred when a nurse or nursing student was asked by an agency to do something outside their defined scope of practice that impaired their nursing license. It is always up toyouto protectyournursing license and follow the state’s Nurse Practice Act when providing patient care.

Federal Regulations

In addition to nursing scope of practice and standards being defined by the American Nurses Association, state Nurse Practice Acts, and employer policies, procedures, and protocols, nursing practice is also influenced by federal regulations enacted by agencies such as the Joint Commission and the Centers for Medicare and Medicaid.

The Joint Commission

The Joint Commission is a national organization that accredits and certifies over 20,000 health care organizations in the United States. The mission of The Joint Commission (TJC) is to continuously improve health care for the public by inspiring health care organizations to excel in providing safe and effective care of the highest quality and value. [10]The Joint Commission sets standards for providing safe, high-quality health care.

NATIONAL PATIENT SAFETY GOALS

The Joint Commission establishes annual National Patient Safety Goals for various types of agencies based on data regarding current national safety concerns. [11]For example, National Patient Safety Goals for hospitals include the following:

Identify Patients Correctly
Improve Staff Communication
Use Medicines Safely
Use Alarms Safely
Prevent Infection
Identify Patient Safety Risks
Prevent Mistakes in Surgery

Nurses, nursing students, and other staff members are expected to incorporate actions related to these safety goals into their daily patient care. For example, SBAR (Situation, Background, Assessment, and Recommendation) handoff reporting techniques, bar code scanning equipment, and perioperative team “time-outs” prior to surgery are examples of actions incorporated at agencies based on National Patient Safety Goals. Nursing programs also use National Patient Safety Goals to guide their curriculum and clinical practice expectations. National Patient Safety Goals are further discussed in the “Safety” chapter of this book.

Use the hyperlinks provided below to read more about The Joint Commission and National Patient Safety Goals.

The Joint Commission

The Joint Commissions’ National Patient Safety Goals

JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE

The Joint Commission Center for Transforming Healthcare was developed in 2008 to help agencies develop effective solutions for critical safety problems with a goal to ultimately achieve zero harm to patients. Some of the projects the Center has developed include improved hand hygiene, effective handoff communications, and safe and effective use of insulin. The Center has also been instrumental in creating a focus on a safety culture in health care organizations. Asafety cultureempowers nurses, nursing students, and other staff members to speak up about their concerns about patient risks and to report errors and near misses, all of which drive improvement in patient care and reduce the incidences of patient harm. [12]Many health care agencies have implemented a safety culture in their workplace and successfully reduced incidences of patient harm. An example of a safety culture action is a nurse or nursing student creating an incident report when an error occurs when administering medication. The incident report is used by the agency to investigate system factors that contribute to errors. To read more about creating a safety culture, use the hyperlink provided below.

References

1.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association↵.
2.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association↵.
3.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association↵.
4.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association↵.
5.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
6.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
7.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
8.: Bostain, L. (2020, June 25). Nursing professionalism begins with you.American Nurse.https://www.myamericannurse.com/nursing-professionalism-begins-with-you/↵.
9.: Wisconsin Administrative Code. (2018).Chapter N 6 standards of practice for registered nurses and licensed practical nurses.https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵.
10.: The Joint Commission. (n.d.).https://www.jointcommission.org/↵.
11.: The Joint Commission. (n.d.).National patient safety goals.https://www.jointcommission.org/standards/national-patient-safety-goals/↵.
12.: Joint Commission Center for Transforming Healthcare. (n.d.).Creating a safety culture.https://www.centerfortransforminghealthcare.org/why-work-with-us/video-resources/creating-a-safety-culture↵.
13.: This work is a derivative ofNursing SkillsbyOpen RNand is licensed underCC BY 4.0↵.

1.4. HEALTH CARE SETTINGS & TEAM

Health Care Settings

There are several levels of health care including primary, secondary, and tertiary care. Each of these levels focuses on different aspects of health care and is typically provided in different settings.

Primary Care

Primary carepromotes wellness and prevents disease. This care includes health promotion, education, protection (such as immunizations), early disease screening, and environmental considerations. Settings providing this type of health care include physician offices, public health clinics, school nursing, and community health nursing.

Secondary care

Secondary careoccurs when a person has contracted an illness or injury and requires medical care. Secondary care is often referred to as acute care. Secondary care can range from uncomplicated care to repair a small laceration or treat a strep throat infection to more complicated emergent care such as treating a head injury sustained in an automobile accident. Whatever the problem, the patient needs medical and nursing attention to return to a state of health and wellness. Secondary care is provided in settings such as physician offices, clinics, urgent care facilities, or hospitals. Specialized units include areas such as burn care, neurosurgery, cardiac surgery, and transplant services.

Tertiary Care

Tertiary careaddresses the long-term effects from chronic illnesses or conditions with the purpose to restore a patient’s maximum physical and mental function. The goal of tertiary care is to achieve the highest level of functioning possible while managing the chronic illness. For example, a patient who falls and fractures their hip will need secondary care to set the broken bones, but may need tertiary care to regain their strength and ability to walk even after the bones have healed. Patients with incurable diseases, such as dementia, may need specialized tertiary care to provide support they need for daily functioning. Tertiary care settings include rehabilitation units, assisted living facilities, adult day care, skilled nursing units, home care, and hospice centers.

Health Care Team

No matter the setting, quality health care requires a team of health care professionals collaboratively working together to deliver holistic, individualized care. Nursing students must be aware of the roles and contributions of various health care team members. The health care team consists of health care providers, nurses (licensed practical nurses, registered nurses, and advanced registered nurses), unlicensed assistive personnel, and a variety of interprofessional team members.

Health Care Providers

The Wisconsin Nurse Practice Act defines aprovideras, “A physician, podiatrist, dentist, optometrist, or advanced practice nurse.” [1]Providers are responsible for ordering diagnostic tests such as blood work and X-rays, diagnosing a patient’s medical condition, developing a medical treatment plan, and prescribing medications. In a hospital setting, the medical treatment plan developed by a provider is communicated in the “History and Physical” component of the patient’s medical record with associated prescriptions (otherwise known as “orders”). Prescriptions or “orders” include diagnostic and laboratory tests, medications, and general parameters regarding the care that each patient is to receive. Nurses should respectfully clarify prescriptions they have questions or concerns about to ensure safe patient care. Providers typically visit hospitalized patients daily in what is referred to as “rounds.” It is helpful for nurses and nursing students to attend provider rounds for their assigned patients to be aware of and provide input regarding the current medical treatment plan, seek clarification, or ask questions. This helps to ensure that the provider, nurse, and patient have a clear understanding of the goals of care and minimize the need for follow-up phone calls.

Nurses

There are three levels of nurses as defined by each state’s Nurse Practice Act: Licensed Practical Nurse/Vocational Nurse (LPN/LVN), Registered Nurse (RN), and Advanced Practice Nurse (APRN).

LICENSED PRACTICAL/VOCATIONAL NURSES

The NCSBN defines alicensed practical nurse(LPN)as, “An individual who has completed a state-approved practical or vocational nursing program, passed the NCLEX-PN examination, and is licensed by a state board of nursing to provide patient care.” [2]In some states, the term licensed vocational nurse (LVN) is used. LPN/LVNs typically work under the supervision of a registered nurse, advanced practice registered nurse, or physician. [3]LPNs provide “basic nursing care” and work with stable and/or chronically ill populations.Basic nursing careis defined by the Wisconsin Nurse Practice Act as “care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.” [4]LPN/LVNs typically collect patient assessment information, administer medications, and perform nursing procedures according to their scope of practice in that state. The Open RNNursing Skillstextbook discusses the skills and procedures that LPNs frequently perform in Wisconsin. See the following box for additional details about the scope of practice of the Licensed Practical Nurse in Wisconsin.

Scope of Practice for Licensed Practical Nurses in Wisconsin

The Wisconsin Nurse Practice Act defines the scope of practice for Licensed Practical Nurses as the following: “In the performance of acts in basic patient situations, the LPN shall, under the general supervision of an RN or the direction of a provider:

a.

Accept only patient care assignments which the LPN is competent to perform.

b.

Provide basic nursing care.

c.

Record nursing care given and report to the appropriate person changes in the condition of a patient.

d.

Consult with a provider in cases where an LPN knows or should know a delegated act may harm a patient.

e.

Perform the following other acts when applicable:

1.: Assist with the collection of data.
2.: Assist with the development and revision of a nursing care plan.
3.: Reinforce the teaching provided by an RN provider and provide basic health care instruction.
4.: Participate with other health team members in meeting basic patient needs.” [5]

REGISTERED NURSES

The NCSBN defines aRegistered Nurseas “An individual who has graduated from a state-approved school of nursing, passed the NCLEX-RN examination and is licensed by a state board of nursing to provide patient care.” [6]Registered Nurses (RNs) use the nursing process as a critical thinking model as they make decisions and use clinical judgment regarding patient care. The nursing process is discussed in more detail in the “Nursing Process” chapter of this book. RNs may be delegated tasks from providers or may delegate tasks to LPNs and UAPs with supervision. See the following box for additional details about the scope of practice for Registered Nurses in the state of Wisconsin.

Scope of Practice for Registered Nurses in Wisconsin

1.

GENERAL NURSING PROCEDURES. An RN shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:

a.: Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.
b.: Planning. Planning is developing a nursing plan of care for a patient, which includes goals and priorities derived from the nursing diagnosis.
c.: Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to LPNs or less skilled assistants.
d.: Evaluation. Evaluation is the determination of a patient’s progress or lack of progress toward goal achievement, which may lead to modification of the nursing diagnosis.

2.

PERFORMANCE OF DELEGATED ACTS. In the performance of delegated acts, an RN shall do all of the following:

a.: Accept only those delegated acts for which there are protocols or written or verbal orders.
b.: Accept only those delegated acts for which the RN is competent to perform based on his or her nursing education, training or experience.
c.: Consult with a provider in cases where the RN knows or should know a delegated act may harm a patient.
d.: Perform delegated acts under the general supervision or direction of provider.

3.

SUPERVISION AND DIRECTION OF DELEGATED ACTS. In the supervision and direction of delegated acts, an RN shall do all of the following:

a.: Delegate tasks commensurate with educational preparation and demonstrated abilities of the person supervised.
b.: Provide direction and assistance to those supervised.
c.: Observe and monitor the activities of those supervised.
d.: Evaluate the effectiveness of acts performed under supervision. [7]

ADVANCED PRACTICE NURSES

Advanced Practice Nurses(APRN)are defined by the NCSBN as an RN who has a graduate degree and advanced knowledge. There are four categories of Advanced Practice Nurses: certified nurse-midwife (CNM), clinical nurse specialist (CNS), certified nurse practitioner (CNP), and certified registered nurse anesthetist (CRNA). APRNs can diagnose illnesses and prescribe treatments and medications. Additional information about advanced nursing degrees and roles is provided in the box below.

Advanced Practice Nursing Roles [8]

Nurse Practitioners:Nurse practitioners (NPs) work in a variety of settings and complete physical examinations, diagnose and treat common acute illness and manage chronic illness, order laboratory and diagnostic tests, prescribe medications and other therapies, provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance, and refer patients to other health professionals and specialists as needed. In many states, NPs can function independently and manage their own clinics, whereas in other states physician supervision is required. NP certifications include, but are not limited to, Family Practice, Adult-Gerontology Primary Care and Acute Care, and Psychiatric/Mental Health.

To read more about NP certification, visitNursing World’sOur Certificationsweb page.

Clinical Nurse Specialists:Clinical Nurse Specialists (CNS) practice in a variety of health care environments and participate in mentoring other nurses, case management, research, designing and conducting quality improvement programs, and serving as educators and consultants. Specialty areas include, but are not limited to, Adult/Gerontology, Pediatrics, and Neonatal.

To read more about CNS certification, visitNACNS’sWhat is a CNS?web page.

Certified Registered Nurse Anesthetists:Certified Registered Nurse Anesthetists (CRNAs) administer anesthesia and related care before, during, and after surgical, therapeutic, diagnostic, and obstetrical procedures, as well as provide airway management during medical emergencies. CRNAs deliver more than 65 percent of all anesthetics to patients in the United States. Practice settings include operating rooms, dental offices, and outpatient surgical centers.

To read more about CRNA certification, visitNBCRNA’s website.

Certified Nurse Midwives:Certified Nurse Midwives provide gynecological exams, family planning advice, prenatal care, management of low-risk labor and delivery, and neonatal care. Practice settings include hospitals, birthing centers, community clinics, and patient homes.

To read more about CNM certification,visitAMCB Midwife’s website.

Unlicensed Assistive Personnel

Unlicensed Assistive Personnel(UAP) are defined by the NCSBN as, “Any unlicensed person, regardless of title, who performs tasks delegated by a nurse. This includes certified nursing aides/assistants (CNAs), patient care assistants (PCAs), patient care technicians (PCTs), state tested nursing assistants (STNAs), nursing assistants-registered (NA/Rs), or certified medication aides/assistants (MA-Cs). Certification of UAPs varies between jurisdictions.” [9]

CNAs, PCAs, and PCTs in Wisconsin generally work in hospitals and long-term care facilities and assist patients with daily tasks such as bathing, dressing, feeding, and toileting. They may also collect patient information such as vital signs, weight, and input/output as delegated by the nurse. The RN remains accountable that delegated tasks have been completed and documented by the UAP.

Interprofessional Team Members

Nurses, as the coordinator of a patient’s care, continuously review the plan of care to ensure all contributions of the multidisciplinary team are moving the patient toward expected outcomes and goals. The roles and contributions of interprofessional health care team members are further described in the following box.

Interprofessional Team Member Roles [10]

Dieticians:Dieticians assess, plan, implement, and evaluate interventions including those relating to dietary needs of those patients who need regular or therapeutic diets. They also provide dietary education and work with other members of the health care team when a client has dietary needs secondary to physical disorders such as dysphagia.

Occupational Therapists (OT):Occupational therapists assess, plan, implement, and evaluate interventions, including those that facilitate the patient’s ability to achieve their highest possible level of independence in their activities of daily living such as bathing, grooming, eating, and dressing. They also provide patients adaptive devices such as long shoe horns so the patient can put their shoes on, sock pulls so they can independently pull on socks, adaptive silverware to facilitate independent eating, grabbers so the patient can pick items up from the floor, and special devices to manipulate buttoning so the person can dress and button their clothing independently. Occupational therapists also assess the home for safety and the need for assistive devices when the patient is discharged home. They may recommend modifications to the home environment such as ramps, grab rails, and handrails to ensure safety and independence. Like physical therapists, occupational therapists practice in all health care environments including the home, hospital, and rehabilitation centers.

Pharmacists:Pharmacists ensure the safe prescribing and dispensing of medication and are a vital resource for nurses with questions or concerns about medications they are administering to patients. Pharmacists ensure that patients not only get the correct medication and dosing, but also have the guidance they need to use the medication safely and effectively.

Physical Therapists (PT):Physical therapists are licensed health care professionals who assess, plan, implement, and evaluate interventions including those related to the patient’s functional abilities in terms of their strength, mobility, balance, gait, coordination, and joint range of motion. They supervise prescribed exercise activities according to a patient’s condition and also provide and teach patients how to use assistive aids like walkers and canes and exercise regimens. Physical therapists practice in all health care environments including the home, hospital, and rehabilitation centers.

Podiatrists:Podiatrists provide care and services to patients who have foot problems. They often work with diabetic patients to clip toenails and provide foot care to prevent complications.

Prosthetists:Prosthetists design, fit, and supply the patient with an artificial body part such as a leg or arm prosthesis. They adjust prosthesis to ensure proper fit, patient comfort, and functioning.

Psychologists and Psychiatrists:Psychologists and psychiatrists provide mental health and psychiatric services to patients with mental health disorders and provide psychological support to family members and significant others as indicated.

Respiratory Therapists:Respiratory therapists treat respiratory-related conditions in patients. Their specialized respiratory care includes managing oxygen therapy; drawing arterial blood gases; managing patients on specialized oxygenation devices such as mechanical ventilators, CPAP, and Bi-PAP machines; administering respiratory medications like inhalers and nebulizers; intubating patients; assisting with bronchoscopy and other respiratory-related diagnostic tests; performing pulmonary hygiene measures like chest physiotherapy; and serving an integral role during cardiac and respiratory arrests.

Social Workers:Social workers counsel patients and provide psychological support, help set up community resources according to patients’ financial needs, and serve as part of the team that ensures continuity of care after the person is discharged.

Speech Therapists:Speech therapists assess, diagnose, and treat communication and swallowing disorders. For example, speech therapists help patients with a disorder calledexpressive aphasia. They also assist patients with using word boards and other electronic devices to facilitate communication. They assess patients with swallowing disorders calleddysphagiaand treat them in collaboration with other members of the health care team including nurses, dieticians, and health care providers.

Ancillary Department Members:Nurses also work with ancillary departments such as laboratory and radiology departments.Clinical laboratory departmentsprovide a wide range of laboratory procedures that aid health care providers to diagnose, treat, and manage patients. These laboratories are staffed by medical technologists who test biological specimens collected from patients. Examples of laboratory tests performed include blood tests, blood banking, cultures, urine tests, and histopathology (changes in tissues caused by disease). [11]Radiology departmentsuse imaging to assist providers in diagnosing and treating diseases seen within the body. They perform diagnostic tests such as X-rays, CTs, MRIs, nuclear medicine, PET scans, and ultrasound scans.

Chain of Command

Nurses rarely make patient decisions in isolation, but instead consult with other nurses and interprofessional team members. Concerns and questions about patient care are typically communicated according to that agency’s chain of command. In the military,chain of commandrefers to a hierarchy of reporting relationships – from the bottom to the top of an organization – regarding who must answer to whom. The chain of command not only establishes accountability, but also lays out lines of authority and decision-making power. The chain of command also applies to health care. For example, a registered nurse in a hospital may consult a “charge nurse,” who may consult the “nurse supervisor,” who may consult the “director of nursing,” who may consult the “vice president of nursing.” In a long-term care facility, a licensed practical/vocational nurse typically consults the registered nurse/charge nurse, who may consult with the director of nursing. Nursing students should always consult with their nursing instructor regarding questions or concerns about patient care before “going up the chain of command.”

Nurse Specialties

Registered nurses can obtain several types of certifications as a nurse specialist.Certificationis the formal recognition of specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty. See the following box for descriptions of common nurse specialties.

Common Nurse Specialties

Critical Care Nursesprovide care to patients with serious, complex, and acute illnesses or injuries that require very close monitoring and extensive medication protocols and therapies. Critical care nurses most often work in intensive care units of hospitals.

Public Health Nurseswork to promote and protect the health of populations based on knowledge from nursing, social, and public health sciences. Public Health Nurses most often work in municipal and state health departments.

Home Health/Hospice Nursesprovide a variety of nursing services for chronically ill patients and their caregivers in the home, including end-of-life care.

Occupational/Employee Health Nursesprovide health screening, wellness programs and other health teaching, minor treatments, and disease/medication management services to people in the workplace. The focus is on promotion and restoration of health, prevention of illness and injury, and protection from work-related and environmental hazards.

Oncology Nursescare for patients with various types of cancer, administering chemotherapy and providing follow-up care, teaching, and monitoring. Oncology nurses work in hospitals, outpatient clinics, and patients’ homes.

Perioperative/Operating Room Nursesprovide preoperative and postoperative care to patients undergoing anesthesia or assist with surgical procedures by selecting and handling instruments, controlling bleeding, and suturing incisions. These nurses work in hospitals and outpatient surgical centers.

Rehabilitation Nursescare for patients with temporary and permanent disabilities within inpatient and outpatient settings such as clinics and home health care.

Psychiatric/Mental Health Nursesspecialize in mental and behavioral health problems and provide nursing care to individuals with psychiatric disorders. Psychiatric nurses work in hospitals, outpatient clinics, and private offices.

School Nursesprovide health assessment, intervention, and follow-up to maintain school compliance with health care policies and ensure the health and safety of staff and students. They administer medications and refer students for additional services when hearing, vision, and other issues become inhibitors to successful learning.

Other common specialty areas include a life span approach across health care settings and include maternal-child, neonatal, pediatric, and gerontological nursing. [12]

Now that we have discussed various settings where nurses work and various nursing roles, let’s review levels of nursing education and the national licensure exam (NCLEX).

References

1.: Wisconsin Administrative Code. (2018).Chapter N 6 standards of practice for registered nurses and licensed practical nurses.https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵.
2.: NCSBN.https://www.ncsbn.org/↵.
3.: NCSBN.https://www.ncsbn.org/index.htm↵.
4.: Wisconsin Administrative Code. (2018).Chapter N 6 standards of practice for registered nurses and licensed practical nurses.https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵.
5.: Wisconsin Administrative Code. (2018).Chapter N 6 standards of practice for registered nurses and licensed practical nurses.https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵.
6.: NCSBN.https://www.ncsbn.org/index.htm↵.
7.: Wisconsin Administrative Code. (2018).Chapter N 6 standards of practice for registered nurses and licensed practical nurses.https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵.
8.: Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine. (2011).The future of nursing: Leading change, advancing health.National Academies Press.https://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-health↵. [PubMed: 24983041]
9.: NCSBN.https://www.ncsbn.org/index.htm↵.
10.: Burke, A. (2020, January 15).Collaboration with interdisciplinary team: NCLEX-RN. RegisteredNursing.org.https://www.registerednursing.org/nclex/collaboration-interdisciplinary-team/#collaborating-healthcare-members-disciplines-providing-client-care↵.
11.: This work is a derivative ofStatPearlsby Bayot and Naidoo and licensed underCC BY 4.0↵.
12.: Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine. (2011).The future of nursing: Leading change, advancing health. National Academies Press.https://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-health↵. [PubMed: 24983041]

1.5. NURSING EDUCATION AND THE NCLEX

Nursing Education and the NCLEX

Everyone who wants to become a nurse has a story to tell about why they want to enter the nursing profession. What is your story? Perhaps it has been a lifelong dream to become a Life Flight nurse, or maybe you became interested after watching a nurse help you or a family member through the birth of a baby, heal from a challenging illness, or assist a loved one at the end of life. Whatever the reason, everyone who wants to become a nurse must do two things: graduate from a state-approved nursing program and pass the National Council Licensure Exam (known as the NCLEX).

Nursing Programs

There are several types of nursing programs you can attend to become a nurse. If your goal is to become aLicensed Practical Nurse (LPN), you must successfully complete a one-year nursing program, pass the NCLEX-PN exam, and apply to your state board of nursing to receive a LPN license.

If you want to become aRegistered Nurse, you can obtain either a two-year associate degree (ADN) or a four-year baccalaureate of science in nursing degree (BSN). Associate degree nursing graduates often enroll into a baccalaureate or higher degree program after they graduate. Many hospitals hire ADN nurses on a condition they complete their BSN within a specific time frame. A BSN is required for military nursing, case management, public health nursing, and school-based nursing services. Another lesser-known option to become an RN is to complete a three-year hospital-based diploma program, which was historically the most common way to become a nurse. Diploma programs have slowly been replaced by college degrees, and now only nine states offer this option.^[1^]After completing a diploma program, associate degree, or baccalaureate degree, nursing graduates must successfully pass the NCLEX-RN to apply for a registered nursing license from their state’s Board of Nursing.

NCLEX

Nursing graduates must successfully pass the National Council Licensure Examination (NCLEX) to receive a nursing license. Registered nurses must successfully pass the NCLEX-RN exam, and Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) must pass the NCLEX-PN exam.

The NCLEX-PN and NCLEX-RN are online, adaptive tests taken at a specialized testing center. The NCLEX tests knowledge, skills, and abilities essential to the safe and effective practice of nursing at the entry level. NCLEX exams are continually reviewed and updated based on surveys of newly graduated nurses every three years.

Both the NCLEX-RN and the NCLEX-PN are variable length tests that adapt as you answer the test items. The NCLEX-RN examination can be anywhere from 75 to 265 items, depending on how quickly you are able to demonstrate your proficiency. Of these items, 15 are unscored test items. The time limit for this examination is six hours. The NCLEX-PN examination can be anywhere from 85 to 205 items. Of these items, 25 are unscored items. The time limit for this examination is five hours.^[2^]

In 2023, the Next Generation NCLEX (NGN) is anticipated to go into effect. Examination questions on the NGN will use the new Clinical Judgment Measurement Model as a framework to measure prelicensure nursing graduates’ clinical judgment and decision-making. The critical thinking model called the “Nursing Process” (discussed in Chapter 4 of this book) will continue to underlie the NGN, but candidates will notice new terminology used to assess their decision-making. For example, candidates may be asked to “recognize cues,” “analyze cues,” “create a hypothesis,” “prioritize hypotheses,” “generate solutions,” “take actions,” or “evaluate outcomes.”^[3^]For this reason, many of the case studies and learning activities included in this book will use similar terminology as the NGN.

There will also be new types of examination questions on the NGN, including case studies, enhanced hot spots, drag and drop ordering of responses, multiple responses, and embedded answer choices within paragraphs of text. View sample NGN questions in the following hyperlink. NCSBN’s rationale for including these types of questions is to “measure the nursing clinical judgment and decision-making ability of prospective entry-level nurses to protect the public’s health and welfare by assuring that safe and competent nursing care is provided by licensed nurses.”^[4^]Similar questions have been incorporated into learning activities throughout this textbook.

Review sample Next Generation NCLEX questions athttps://www.ncsbn.org/NGN-Sample-Questions.pdf.

Nurse Licensure Compact

TheNurse Licensure Compact(NLC)allows a nurse to have one multistate nursing license with the ability to practice in their home state, as well as in other compact states. As of 2020, 33 states have implemented NLC legislation.

Read additional details about theNurse Licensure Compact.

Advanced Nursing Degrees

After obtaining an RN license, nurses can receive advanced degrees to expand their opportunities in the nursing profession.

MASTER’S DEGREE IN NURSING

A Master’s of Science in Nursing Degree (MSN) requires additional credits and years of schooling beyond the BSN. There are a variety of potential focuses in this degree, including Nurse Educator and Advanced Practice Nurse (APRN). Certifications associated with an MSN degree are Certified Nurse Educator (CNE), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Certified Registered Nurse Anesthetist (CRNA), and Certified Nurse Midwife (CNM). Certifications require the successful completion of a certification exam, as well as continuing education requirements to maintain the certification. Scope of practice for advanced practice nursing roles is defined by each state’s Nurse Practice Act.

DOCTORAL DEGREES IN NURSING

Doctoral nursing degrees include the Doctor of Philosophy in Nursing (PhD) and the Doctor of Nursing Practice (DNP). PhD-prepared nurses complete doctoral work that is focused on research. They often teach in a university setting or environment to conduct research. DNP-prepared nurses complete doctoral work that is focused on clinical nursing practice. They typically have work roles in advanced nursing practice, clinical leadership, or academic settings.

Lifelong Learning

No matter what nursing role or level of nursing education you choose, nursing practice changes rapidly and is constantly updated with new evidence-based practices. Nurses must commit to lifelong learning to continue to provide safe, quality care to their patients. Many states require continuing education credits to renew RN licenses, whereas others rely on health care organizations to set education standards and ongoing educational requirements.

Now that we have discussed nursing roles and education, let’s review legal and ethical considerations in nursing.

References

1.: NCSBN. (2019).2018 NCLEX examination statistics 77.https://www.ncsbn.org/2018_NCLEXExamStats.pdf↵.
2.: NCSBN. (2019).NCLEX & Other Exams.https://www.ncsbn.org/nclex.htm↵.
3.: NCSBN. (2021).NCSBN Next Generation NCLEX Project.https://www.ncsbn.org/next-generation-nclex.htm↵.
4.: NCSBN. (2021).NCSBN Next Generation NCLEX Project.https://www.ncsbn.org/next-generation-nclex.htm↵.

1.6. LEGAL CONSIDERATIONS & ETHICS

Legal Considerations

As discussed earlier in this chapter, nurses can be reprimanded or have their licenses revoked for not appropriately following the Nurse Practice Act in the state they are practicing. Nurses can also be held legally liable for negligence, malpractice, or breach of patient confidentiality when providing patient care.

Negligence and Malpractice

Negligenceis a “general term that denotes conduct lacking in due care, carelessness, and a deviation from the standard of care that a reasonable person would use in a particular set of circ*mstances.”^[1^]Malpracticeis a more specific term that looks at a standard of care, as well as the professional status of the caregiver.”^[2^]

To prove negligence or malpractice, the following elements must be established in a court of law:

Duty owed the patient
Breach of duty owed the patient
Foreseeability
Causation
Injury
Damages^[3^]

To avoid being sued for negligence or malpractice, it is essential for nurses and nursing students to follow the scope and standards of practice care set forth by their state’s Nurse Practice Act; the American Nurses Association; and employer policies, procedures, and protocols to avoid the risk of losing their nursing license. Examples of nurses breach of duty that can be viewed as negligence include:^[4^]

Failure to Assess: Nurses should assess for all potential nursing problems/diagnoses, not just those directly affected by the medical disease. For example, all patients should be assessed for fall risk and appropriate fall precautions implemented.
Insufficient monitoring: Some conditions require frequent monitoring by the nurse, such as risk for falls, suicide risk, confusion, and self-injury.
Failure to Communicate:
- Lack of documentation: A basic rule of thumb in a court of law is that if an assessment or action was not documented, it is considered not done. Nurses must document all assessments and interventions, in addition to the specific type of patient documentation called a nursing care plan.
- Lack of provider notification: Changes in patient condition should be urgently communicated to the health care provider based on patient status. Documentation of provider notification should include the date, time, and person notified and follow-up actions taken by the nurse.
Failure to Follow Protocols: Agencies and states have rules for reporting certain behaviors or concerns. For example, a nurse is required to report suspicion of patient, child, or elder abuse based on data gathered during an assessment.

Patient Confidentiality

In addition to negligence and malpractice, patient confidentiality is a major legal consideration for nurses and nursing students.Patient confidentialityis the right of an individual to have personal, identifiable medical information, referred to as protected health information (PHI), kept private. This right is protected by federal regulations called the Health Insurance Portability and Accountability Act (HIPAA). HIPAA was enacted in 1996 and was prompted by the need to ensure privacy and protection of personal health records and data in an environment of electronic medical records and third-party insurance payers. There are two main sections of HIPAA law, the Privacy Rule and the Security Rule. The Privacy Rule addresses the use and disclosure of individuals’ health information. The Security Rule sets national standards for protecting the confidentiality, integrity, and availability of electronically protected health information. HIPAA regulations extend beyond medical records and apply to patient information shared with others. Therefore, all types of patient information should only be shared with health care team members who are actively providing care to them.

How do HIPAA regulations affect you as a student nurse? You are required to adhere to HIPAA guidelines from the moment you begin to provide patient care. Nursing students may be disciplined or expelled by their nursing program for violating HIPAA. Nurses who violate HIPAA rules may be fired from their jobs or face lawsuits. See the following box for common types of HIPAA violations and ways to avoid them.

Common HIPAA Violations and Ways to Avoid Them^[5^]

1.: Gossiping in the hallways or otherwise talking about patients where other people can hear you.It is understandable that you will be excited about what is happening when you begin working with patients and your desire to discuss interesting things that occur. As a student, you will be able to discuss patient care in a confidential manner behind closed doors with your instructor. However, as a health care professional, do not talk about patients in the hallways, elevator, breakroom, or with others who are not directly involved with that patient’s care because it is too easy for others to overhear what you are saying.
2.: Mishandling medical records or leaving medical records unsecured.You can breach HIPAA rules by leaving your computer unlocked for anyone to access or by leaving written patient charts in unsecured locations. You should never share your password with anyone else. Make sure that computers are always locked with a password when you step away from them and paper charts are closed and secured in an area where unauthorized people don’t have easy access to them. NEVER take records from a facility or include a patient’s name on paperwork that leaves the facility.
3.: Illegally or unauthorized accessing of patient files.If someone you know, like a neighbor, coworker, or family member is admitted to the unit you are working on, do not access their medical record unless you are directly caring for them. Facilities have the capability of tracing everything you access within the electronic medical record and holding you accountable. This rule holds true for employees who previously cared for a patient as a student; once your shift is over as a student, you should no longer access that patient’s medical records.
4.: Sharing information with unauthorized people.Anytime you share medical information with anyone but the patient themselves, you must have written permission to do so. For instance, if a husband comes to you and wants to know his spouse’s lab results, you must have permission from his spouse before you can share that information with him. Just confirming or denying that a patient has been admitted to a unit or agency can be considered a breach of confidentiality.
5.: Information can generally be shared with the parents of children until they turn 18, although there are exceptions to this rule if the minor child seeks birth control, an abortion, or becomes pregnant.After a child turns 18, information can no longer be shared with the parent unless written permission is provided, even if the minor is living at home and/or the parents are paying for their insurance or health care. As a general rule, any time you are asked for patient information, check first to see if the patient has granted permission.
6.: Texting or e-mailing patient information on an unencrypted device.Only use properly encrypted devices that have been approved by your health care facility for e-mailing or faxing protected patient information. Also, ensure that the information is being sent to the correct person, address, or phone number.
7.: Sharing information on social media.Never post anything on social media that has anything to do with your patients, the facility where you are working or have clinical, or even how your day went at the agency. Nurses and other professionals have been fired for violating HIPAA rules on social media.^[6^],^[7^],^[8^]

Social Media Guidelines

Nursing students, nurses, and other health care team members must use extreme caution when posting to Facebook, Instagram, Twitter, Snapchat, and other social media sites. Information related to patients, patient care, and/or health care agencies should never be posted on social media; health care team members who violate this guideline can lose their jobs and may face legal action and students can be disciplined or expelled from their nursing program. Be aware that even if you think you are posting in a private group, the information can become public.

The American Nurses Association (ANA) has established the following principles for nurses using social media:^[9^]

Nurses must not transmit or place online individually identifiable patient information.
Nurses must observe ethically prescribed professional patient-nurse boundaries.
Nurses should understand that patients, colleagues, organizations, and employers may view postings.
Nurses should take advantage of privacy settings and seek to separate personal and professional information online.
Nurses should bring content that could harm a patient’s privacy, rights, or welfare to the attention of appropriate authorities.
Nurses should participate in developing organizational policies governing online conduct.

In addition to these principles, the ANA has also provided these tips for nurses and nursing students using social media:^[10^]

Remember that standards of professionalism are the same online as in any other circ*mstance.
Do not share or post information or photos gained through the nurse-patient relationship.
Maintain professional boundaries in the use of electronic media. Online contact with patients blurs this boundary.
Do not make disparaging remarks about patients, employers, or coworkers, even if they are not identified.
Do not take photos or videos of patients on personal devices, including cell phones.
Promptly report a breach of confidentiality or privacy.

View theSocial Media Guidelines for Nursesvideo from the National Council of State Boards of Nursing (NCSBN) on using social media responsibly.

Code of Ethics

In addition to legal considerations, there are also several ethical guidelines for nursing care.

There is a difference between morality, ethical principles, and acode of ethics.Moralityrefers to “personal values, character, or conduct of individuals within communities and societies.”^[11^]Anethical principleis a general guide, basic truth, or assumption that can be used with clinical judgment to determine a course of action. Four common ethical principles are beneficence (do good), nonmaleficence (do no harm), autonomy (control by the individual), and justice (fairness). A code of ethics is set for a profession and makes their primary obligations, values, and ideals explicit.

The American Nursing Association (ANA) guides nursing practice with theCode of Ethics for Nurses.^[12^]This code provides a framework for ethical nursing care and a guide for decision-making. The Code of Ethics for Nurses serves the following purposes:

It is a succinct statement of the ethical values, obligations, duties, and professional ideals of nurses individually and collectively.
It is the profession’s nonnegotiable ethical standard.
It is an expression of nursing’s own understanding of its commitment to society.^[13^]

The ANA Code of Ethics contains nine provisions. See a brief description of each provision in the following box.

Provisions of the ANA Code of Ethics^[14^]

The nine provisions of the ANA Code of Ethics are briefly described below. The full code is available to read for free atNursingworld.org.

Provision 1:The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

Provision 2:The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.

Provision 3:The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

Provision 4:The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.

Provision 5:The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

Provision 6:The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.

Provision 7:The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

Provision 8:The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

Provision 9:The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

The ANA Center for Ethics and Human Rights

In addition to publishing the Code of Ethics, the ANA Center for Ethics and Human Rights was established to help nurses navigate ethical and value conflicts and life-and-death decisions, many of which are common to everyday practice.

References

1.: Missouri Department of Health & Senior Services. (n.d.).Negligence and malpractice.https://health.mo.gov/living/lpha/phnursing/negligence.php#:~:text=Negligence%20is%3A,a%20particular%20set%20of%20circ*mstances.↵.
2.: Missouri Department of Health & Senior Services. (n.d.).Negligence and malpractice.https://health.mo.gov/living/lpha/phnursing/negligence.php#:~:text=Negligence%20is%3A,a%20particular%20set%20of%20circ*mstances.↵.
3.: Missouri Department of Health & Senior Services. (n.d.).Negligence and malpractice.https://health.mo.gov/living/lpha/phnursing/negligence.php#:~:text=Negligence%20is%3A,a%20particular%20set%20of%20circ*mstances.↵.
4.: Vera, M. (2020).Nursing care plan (NCP): Ultimate guide and database.https://nurseslabs.com/nursing-care-plans/#:~:text=Collaborative%20interventions%20are%20actions%20that,to%20gain%20their%20professional%20viewpoint.↵.
5.: Patterson, A. (2018, July 3).Most common HIPAA violations with examples. Inspired eLearning.https://inspiredelearning.com/blog/hipaa-violation-examples/↵.
6.: Karimi H., Masoudi Alavi N. Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies. 2015;4(2):e29475. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557413/ ↵ [PMC free article: PMC4557413] [PubMed: 26339672]
7.: American Nurses Association. (n.d.).About ANA.https://www.nursingworld.org/ana/about-ana/↵.
8.: American Nurses Association. (n.d.).Scope of practice.https://www.nursingworld.org/practice-policy/scope-of-practice/↵.
9.: American Nurses Association. (n.d.).Social media.https://www.nursingworld.org/social/↵.
10.: American Nurses Association. (n.d.).Social media.https://www.nursingworld.org/social/↵.
11.: American Nurses Association. (2015).Code of ethics for nurses with interpretive statements. American Nurses Association.https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/↵.
12.: American Nurses Association. (2015).Code of ethics for nurses with interpretive statements. American Nurses Association.https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/↵.
13.: American Nurses Association. (2015).Code of ethics for nurses with interpretive statements. American Nurses Association.https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/↵.
14.: American Nurses Association. (2015).Code of ethics for nurses with interpretive statements. American Nurses Association.https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/↵.

1.7. PROFESSIONAL ORGANIZATIONS

Professional Nursing Organizations

In addition to the ANA’sNursing: Scope and Standards of PracticeandCode of Ethics for Nurses, there are several professional nursing organizations that provide specialized standards for nursing care and promote continuous quality improvement. The following box contains examples of many organizations that significantly guide the overall nursing profession.

Examples of Professional Nursing Organizations

American Nursing Association

As described previously in this chapter, the American Nurses Association (ANA) guides professional nursing practice with publications, in addition to establishing the ANA Scope and Standards of Practice and ANA Code of Ethics. The ANA also publishes a monthly journal on nursing topics for its members calledThe American Nurse.

American Nurses Credentialing Center

The American Nurses Credentialing Center (ANCC) credentials both organizations and individuals. ANCC certification provides individual nurses certification in specialized nursing knowledge.

The ANCC accreditation program recognizes the importance of high-quality continuing nursing education, interprofessional continuing education, transition to practice programs, and skills-based competency programs. Around the world, ANCC-accredited organizations provide nurses with the knowledge and skills to help improve care and patient outcomes.

Academy of Medical-Surgical Nurses

Wound, Ostomy and Continence Nursing

Perioperative Nursing

Association of Women’s Health, Obstetric, and Neonatal Nurses

View theAMSN YouTube video^[4^]from the former president of the Academy of Medical-Surgical Nurses about important nursing issues.

References

1.: Wisconsin Administrative Code. (2018).Chapter N 6 standards of practice for registered nurses and licensed practical nurses.https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf ↵
2.: National Student Nurses’ Association. (n.d.).About us.https://www.nsna.org/about-nsna.html ↵
3.: American Nurses Association. (n.d.).Scope of practice.https://www.nursingworld.org/practice-policy/scope-of-practice/↵

1.8. QUALITY AND EVIDENCE-BASED PRACTICE

The American Nursing Association (ANA), various professional nursing organizations, and federal agencies continually work to improve the quality of patient care. Nurses must also be individually dedicated to providing quality patient care based on current evidence-based practices.

Quality of Practice

One of the American Nurses Association (ANA) Standards of Professional Practice is “Quality of Practice.” This standard emphasizes that “nursing practice is safe, effective, efficient, equitable, timely, and person-centered.”^[1^]Qualityis defined as, “The degree to which nursing services for healthcare consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge.”^[2^]Every nurse is responsible for providing quality care to their patients by following the standards set forth by various organizations, as well as personally incorporating evidence-based practice. Quality is everyone’s responsibility and it takes the entire health care team to ensure that quality care is provided to each and every patient. For example, turning an immobile patient every two hours to prevent pressure injuries requires the dedication of many staff members throughout the day and night. Quality actions can also be formalized on a specific unit, such as the review of data related to patient falls with specific unit-based interventions formally put into place. This commitment to quality practice requires lifelong learning after you have completed your formal nursing education to remain current with new evidence-based practices.

Learning how to provide safe, quality nursing practice begins in nursing school. The Quality and Safety Education for Nurses (QSEN) project encourages future nurses to continuously improve the quality and safety of the health care systems in which they work. The vision of the QSEN project is to “inspire health care professionals to put quality and safety as core values to guide their work.”^[3^]Nurses and nursing students are expected to participate in quality improvement (QI) initiatives by identifying gaps where change is needed and implementing initiatives to resolve these gaps.Quality improvementis defined as the combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners, and educators – to make the changes that will lead to optimal patient outcomes (health), improved system performance (care), and enhanced professional development (learning).^[4^]As a nursing student, you can immediately begin to contribute to improving the quality of nursing practice by participating in quality improvement initiatives.

Evidence-Based Practice in Nursing

Evidence-based practiceis a component of ANA’s “Scholarly Inquiry” Standard of Professional Practice. Evidence-based practice is defined as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the healthcare consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.”^[5^]

Utilizing evidence-based practice means that nurses and nursing students provide patient care based on research studies and clinical expertise and do not just do something “because that’s the way we’ve always done it.” A simple example of nurses promoting evidence-based practice to help patients is using peppermint to relieve nausea. Throughout history, peppermint was used for an upset stomach and to relieve the feeling of nausea. This idea was frequently rejected in the medical field because there was no scientific evidence to support it. However, In 2016, Lynn Bayne and Helen Hawrylack, two nurse researchers, developed a peppermint inhaler for patients to use when they were feeling nauseated and found it was 93% effective in relieving nausea.^[6]

Nursing students should implement evidence-based practice as they begin their nursing career by ensuring the resources they use to prepare for patient care are valid and credible. For this reason, hyperlinks to credible and reliable sources are provided throughout this textbook.

References

1.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association↵.
2.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association↵.
3.: QSEN Institute. (n.d.).Project overview.http://qsen.org/about-qsen/project-overview/↵.
4.: Batalden P. B., Davidoff F. What is "quality improvement" and how can it transform healthcare? BMJ Quality & Safety. 2007;16(1):2–3. ↵ [PMC free article: PMC2464920] [PubMed: 17301192] [CrossRef]
5.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
6.: ChristianaCare News. (2016, May 16).Nurse researchers develop peppermint inhaler to relieve post-op nausea.https://news.christianacare.org/2016/05/nurse-researchers-develop-peppermint-inhaler-to-relieve-post-op-nausea/↵.

1.9. LEARNING ACTIVITIES

Learning Activities

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

Apply what you have learned from this chapter by completing the following learning activities:

1.: You are a nursing student observing the Critical Care Unit (CCU) as part of your clinical course. You have been assisting a critical care nurse with the care of a patient who has been experiencing significantly low blood pressures throughout the day. The nurse has to step away from the bedside to take a phone call and instructs you to increase the intravenous (IV) medication if the patient’s systolic blood pressure drops below 90 mmHg. What is the appropriate response to this instruction?
2.: You are completing a clinical rotation on a medical surgical unit and are invited to join a few staff nurses in the breakroom for a lunch break. While you are in the breakroom, you notice one of the staff nurses complaining loudly about a patient and discussing sensitive patient care information. What is an appropriate response to this situation?

I. GLOSSARY

Advanced Practice Nurse (APRN): An RN who has a graduate degree and advanced knowledge. There are four categories of APRNs: certified nurse-midwife (CNM), clinical nurse specialist (CNS), certified nurse practitioner (CNP), or certified registered nurse anesthetist (CRNA). These nurses can diagnose illnesses and prescribe treatments and medications.^[1^]
ANA Standards of Professional Nursing Practice: Authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. The Standards of Professional Nursing Practice describe a competent level of nursing practice 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.^[2^]
ANA Standards of Professional Performance: Standards that describe a competent level of behavior in the professional role of the nurse, including activities related to ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship, and environmental health.^[3^]
Basic nursing care: Care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.^[4^]
Board of Nursing: The state-specific licensing and regulatory body that sets the standards for safe nursing care, decides the scope of practice for nurses within its jurisdiction, and issues licenses to qualified candidates.
Chain of command: A hierarchy of reporting relationships in an agency that establishes accountability and lays out lines of authority and decision-making power.
Code of ethics: A code that applies normative, moral guidance for nurses in terms of what they ought to do, be, and seek. A code of ethics makes the primary obligations, values, and ideals of a profession explicit.
Dysphagia: Impaired swallowing.
Ethical principle: An ethical principle is a general guide, basic truth, or assumption that can be used with clinical judgment to determine a course of action. Four common ethical principles are beneficence (do good), nonmaleficence (do no harm), autonomy (control by the individual), and justice (fairness).
Evidence-based practice: A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.^[5^]
Expressive aphasia: The impaired ability to form words and speak.
Licensed Practical Nurse/Vocational Nurse (LPN/LVN): An individual who has completed a state-approved practical or vocational nursing program, passed the NCLEX-PN examdination, and is licensed by their state Board of Nursing to provide patient care.^[6^]
Malpractice: A specific term that looks at a standard of care, as well as the professional status of the caregiver.^[7^]
Morality: Personal values, character, or conduct of individuals within communities and societies.^[8^]
Negligence: A “general term that denotes conduct lacking in due care, carelessness, and a deviation from the standard of care that a reasonable person would use in a particular set of circ*mstances.”^[9^]
Nurse Licensure Compact (NLC): Allows a nurse to have one multistate license with the ability to practice in the home state and other compact states.
Nursing: Nursing integrates the art and science of caring and focused 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.^[10^]
Nurse Practice Act (NPA): Legislation enacted by each state that establishes regulations for nursing practice within that state by defining the requirements for licensure, as well as the scope of nursing practice.
Patient confidentiality: Keeping your patient’s Protected Health Information (PHI) protected and known only by those health care team members directly providing care for the patient.
Primary care: Care that is provided to patients to promote wellness and prevent disease from occurring. This includes health promotion, education, protection (such as immunizations), early disease screening, and environmental considerations.
Protocol: A precise and detailed written plan for a regimen of therapy.^[11^]
Provider: A physician, podiatrist, dentist, optometrist, or advanced practice nurse provider.^[12^]
Quality: The degree to which nursing services for health care consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge.”^[13^]
Registered Nurse (RN): An individual who has graduated from a state-approved school of nursing, passed the NCLEX-RN examination, and is licensed by a state board of nursing to provide patient care.^[14^]
Safety culture: A culture established within health care agencies that empowers nurses, nursing students, and other staff members to speak up about risks to patients and to report errors and near misses, all of which drive improvement in patient care and reduce the incident of patient harm.
Scope of practice: Services that a qualified health professional is deemed competent to perform and permitted to undertake – in keeping with the terms of their professional license.
Secondary care: Care that occurs when a person has contracted an illness or injury and is in need of medical care.
Tertiary care: A type of care that deals with the long-term effects from chronic illness or condition, with the purpose to restore physical and mental function that may have been lost. The goal is to achieve the highest level of functioning possible with this chronic illness.
Unlicensed Assistive Personnel: Any unlicensed person, regardless of title, who performs tasks delegated by a nurse. This includes certified nursing aides/assistants (CNAs), patient care assistants (PCAs), patient care technicians (PCTs), state tested nursing assistants (STNAs), nursing assistants-registered (NA/Rs) or certified medication aides/assistants (MA-Cs). Certification of UAPs varies between jurisdictions.^[15^]

References

1.: NCSBN.https://www.ncsbn.org/index.htm↵.
2.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
3.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
4.: Wisconsin Administrative Code. (2018).Chapter N 6 standards of practice for registered nurses and licensed practical nurses.https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵.
5.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
6.: NCSBN.https://www.ncsbn.org/index.htm↵.
7.: Missouri Department of Health & Senior Services. (n.d.).Negligence and malpractice.https://health.mo.gov/living/lpha/phnursing/negligence.php#:~:text=Negligence%20is%3A,a%20particular%20set%20of%20circ*mstances.↵.
8.: American Nurses Association. (2015).Code of ethics for nurses with interpretive statements. American Nurses Association.https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/↵.
9.: Missouri Department of Health & Senior Services. (n.d.).Negligence and malpractice.https://health.mo.gov/living/lpha/phnursing/negligence.php#:~:text=Negligence%20is%3A,a%20particular%20set%20of%20circ*mstances.↵.
10.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
11.: Wisconsin Administrative Code. (2018).Chapter N 6 standards of practice for registered nurses and licensed practical nurses.https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵.
12.: Wisconsin Administrative Code. (2018).Chapter N 6 standards of practice for registered nurses and licensed practical nurses.https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf↵.
13.: American Nurses Association. (2021).Nursing: Scope and standards of practice(4th ed.). American Nurses Association.↵.
14.: NCSBN.https://www.ncsbn.org/index.htm↵.
15.: NCSBN.https://www.ncsbn.org/index.htm↵.

Chapter 1 Scope of Practice (2024)

1.1. SCOPE OF PRACTICE INTRODUCTION

Learning Objectives

References

1.2. HISTORY AND FOUNDATION

Brief History of Nursing

Figure 1.1

American Nurses Association (ANA)

Read more information about theAmerican Nurses Association

View theDiscover the American Nurses Associationvideo. [7]

References

1.3. REGULATIONS & STANDARDS

ANA Scope and Standards of Practice

Nurse Practice Act

Read more details about the Wisconsin Administrative Code and theBoard of Nursing.

Read about Wisconsin Standards of Practice for Nurses inChapter N 6.

Read about Wisconsin Rules of Conduct inChapter N 7.

Employer Policies, Procedures, and Protocols

Federal Regulations

The Joint Commission

NATIONAL PATIENT SAFETY GOALS

The Joint Commission

The Joint Commissions’ National Patient Safety Goals

JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE

Read more aboutCreating a Safety Culture.

Centers for Medicare & Medicaid Services

References

1.4. HEALTH CARE SETTINGS & TEAM

Health Care Settings

Primary Care

Secondary care

Tertiary Care

Health Care Team

Health Care Providers

Nurses

LICENSED PRACTICAL/VOCATIONAL NURSES

Scope of Practice for Licensed Practical Nurses in Wisconsin

REGISTERED NURSES

Scope of Practice for Registered Nurses in Wisconsin

ADVANCED PRACTICE NURSES

Advanced Practice Nursing Roles [8]

Unlicensed Assistive Personnel

Interprofessional Team Members

Interprofessional Team Member Roles [10]

Chain of Command

Nurse Specialties

Common Nurse Specialties

References

1.5. NURSING EDUCATION AND THE NCLEX

Nursing Education and the NCLEX

Nursing Programs

NCLEX

Read more information about theNCLEX & Test Plans.

Review sample Next Generation NCLEX questions athttps://www.ncsbn.org/NGN-Sample-Questions.pdf.

Nurse Licensure Compact

Read additional details about theNurse Licensure Compact.

Advanced Nursing Degrees

MASTER’S DEGREE IN NURSING

DOCTORAL DEGREES IN NURSING

Lifelong Learning

References

1.6. LEGAL CONSIDERATIONS & ETHICS

Legal Considerations

Negligence and Malpractice

Patient Confidentiality

Common HIPAA Violations and Ways to Avoid Them[5]

Social Media Guidelines

Read more about the ANA’sSocial Media Principles.

View theSocial Media Guidelines for Nursesvideo from the National Council of State Boards of Nursing (NCSBN) on using social media responsibly.

Code of Ethics

Provisions of the ANA Code of Ethics[14]

The ANA Center for Ethics and Human Rights

Read more information about theANA Center for Ethics and Human Rights.

References

1.7. PROFESSIONAL ORGANIZATIONS

Professional Nursing Organizations

Examples of Professional Nursing Organizations

American Nursing Association

American Nurses Credentialing Center

Read more about theAmerican Nurses Credentialing Center

Common HIPAA Violations and Ways to Avoid Them^[5^]

Provisions of the ANA Code of Ethics^[14^]

View theAMSN YouTube video^[4^]from the former president of the Academy of Medical-Surgical Nurses about important nursing issues.