The purpose of standards of clinical nursing practice is to describe the responsibilities for which nurses are held accountable. The standards for nursing practice:
1) Reflect the values and priorities of the nursing profession;
2) Provide direction for professional nursing;
3) Provide a framework for the evaluation of nursing practice;
4) Define the profession’s accountability to the public and the client outcomes for which nurses are responsible.
The first Standards of Nursing Practice were published by the American Nurses Association (ANA) in 1973. They were stated according to a systematic approach to nursing practice through the use of the nursing process. The specific components of the nursing process were not intended to imply that practice consists of a series of discrete steps taken in strict sequence, beginning with assessment and ending with evaluation, but rather the components are used concurrently and recurrently. Assessment for example, frequently continues during implementation. Similarly, evaluation dictates reassessment and replanning.
The standards apply to nursing practice in any setting. Nursing practice in all settings must possess the characteristics identified by the standards if clients/patients are to receive a high quality of nursing care. Each standard contains rationale and assessment factors.
The assessment factors are used in determining achievement of the standard.
The first revision of the standards was undertaken in 1990 with completion and publication in 1991. The Standards of Clinical Nursing Practice applies to the care that is provided to all clients. “Clients” may include any individual, family, group or community for whom the nurse is providing services formally specified as sanctioned by the nurse practice acts. They are generic in nature and apply to all registered nurses engaged in clinical practice regardless of clinical specialty, practice setting or educational preparation.
Standards that further define the responsibilities of nurses engaged in specialty practice or nurses who function at advanced levels of clinical practice are determined by those nursing specialties and appropriate groups within ANA.
The Standards of Clinical Practice are as follows. The written text also provides the nurse with the measurement criteria for the registered nurse, the advanced practice nurse and the role specialist nurse.
• Standard No. 1: Assessment
The registered nurse collects comprehensive data pertinent to the patient’s health or the situation.
• Standard No. 2: Diagnosis
The registered nurse analyzes the assessment data to determine the diagnoses or issues.
• Standard No. 3: Outcomes Identification
The registered nurse identifies expected outcomes for a plan individualized to the patient or the situation.
• Standard No. 4: Planning
The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
• Standard No. 5: Implementation
The registered nurse implements the identified plan.
• Standard No. 5b: Health Teaching and Health Promotion
The registered nurse employs strategies to promote health and a safe environment.
• Standard No. 5c: Consultation
The advanced practice registered nurse and the nursing role specialist provide consultation to influence the identified plan, enhance the abilities of others and affect change.
• Standard No. 5d: Prescriptive Authority and Treatment
The advanced practice registered nurse uses prescriptive authority, procedures, referrals, treatments and therapies in accordance with state and federal laws and regulations.
• Standard No. 6: Evaluation
The registered nurse evaluates progress toward attainment of outcomes. The registered nurse coordinates care delivery.
Source: American Nurses Association (2004). Nursing: Scope and Standards of Practice. Washington, D.C.; Nursesbooks.org.
Standards of care describe a competent level of nursing care as demonstrated by the nursing process involving assessment, diagnosis, outcome identification, planning, implementation and evaluation. The nursing process encompasses the significant actions taken by nurses in providing care to all clients, and forms the foundation of clinical decision making. Additional nursing responsibilities for all clients such as providing culturally and ethnically relevant care, maintaining a safe environment, educating clients about their illness, treatment, health promotion or self-care activities and planning for continuity of care are subsumed within these standards.
Standards of Professional Performance are included in this revision which describe a competent level of behavior in the professional role including activities related to quality of care, performance appraisal, education, collegiality, ethics, collaboration, research and resource utilization.
All nurses are expected to engage in professional role activities appropriate to their education, position and practice setting. Standards for specialty and/or specialty practice may elaborate on appropriate expectations for the various professional role standards in these specialties. These standards are set forth by the appropriate specialty group or organization such as The American Association of Neuroscience Nurses (AANN), The American Association of Critical Care Nurses (AACCN) and the American Association of Nurse Anesthetists (AANA), just to name a few.
The standards of care are the yardstick that is used by the legal system to measure the actions of a nurse who is involved in any type of nursing negligence or malpractice. The underlying principle used to establish standards of care is based on the actions that would likely be taken by a reasonable person (nurse) who was placed in a same or similar situation. A nurse is judged against the standards of care that have been established within the profession and specialty area of practice. The ANA and appropriate specialty organizations publish these standards, which are updated continually as healthcare technology and practices change.
Until recently, nurses were held to the standards of the local community, however this is rapidly changing. National criteria have now replaced most locality rule standards of care. Nurses are now held accountable not only to the adaptable standards within their local community but to the national standards (ANA) as well.
The Nurse Practice Acts in each state control the practice of nursing through licensing. They legally define the practice of nursing within the specific state, thereby describing the scope of nursing and protecting the public. They set the requirements for licensure, including educational requirements, and they describe the legal titles and abbreviations that a nurse may use.
The practice parameters of nursing are regulated by the individual states through regulatory agencies and boards. These boards are established by state legislation and are given statutory authority by state legislatures to enforce professional practice acts. Individuals cannot legally practice nursing without a license.
While the nurse practice acts vary in scope from one state to another, they tend to have similar wording based loosely on the ANA model that was published in 1988. The Standards of Nursing Practice are woven into the Nursing Practice Acts of the individual states. They are usually found within the definition of nursing at the beginning of the practice act.
As nursing has evolved into the profession that it is, each individual nurse has the responsibility to have read the Nurse Practice Act of his particular state and to understand the standards of care that are set forth in that state’s practice act, policies and procedures established by the healthcare facility where he works and other standards applicable to his practice.
Nurses have come a long way from “caregiver and physician-helper.” They are no longer under the control or protection of the physician or healthcare organizations. They are responsible and accountable for their actions as described in nursing’s scope of practice as defined by the state nurse practice act.
Know how your individual state defines nursing and its scope of practice, and become familiar with the ANA’s Standards for Clinical Nursing Practice — they protect you and the public we serve. •
Frances W. (Billie) Sills, RN, MSN, ARNP, is an assistant professor at ETSU College of Nursing in Tennessee and a member of this paper’s editorial board;firstname.lastname@example.org.