SECTION 1 Concepts in Nursing Practice
1
Professional Nursing
Mariann M. Harding
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Care Competencies Clinical Judgment
Leadership Professional Identity
LEARNING OUTCOMES
1. Describe the domain and definition of professional nursing 5. Explore the role of the professional nurse in delegating
practice. care to licensed practical/vocational nurses and assistive
2. Compare the different scopes of practice available to personnel.
professional nurses. 6. Discuss the role of integrating safety and quality
3. Describe the role of clinical judgment skills and using a improvement processes into nursing practice.
clinical practice framework to provide patient-centered 7. Evaluate the role of informatics and health care technology
care. in nursing practice.
4. Apply the SBAR procedure and effective communication 8. Apply concepts of evidence-based practice to nursing
techniques in the clinical setting. practice.
KEY TERMS
advanced practice registered nurse (APRN) interprofessional team
clinical pathways nursing
clinical judgment nursing process
delegation patient handoff
electronic health records (EHRs) SBAR (Situation-Background-Assessment-Recommendation)
evidence-based practice (EBP) serious reportable event (SRE)
failure to rescue telehealth
This chapter presents an overview of professional nursing practice, You have never been more important to health care than you
discussing the wide variety of roles and responsibilities nurses fulfill are today. As a nurse, you are at the forefront of patient care (Fig.
to meet society’s health care needs. This overview includes the core 1.1). Beyond nursing’s reputation for compassion and dedica-
abilities that are part of competent nursing practice. These include tion lies a highly specialized profession.1 Nursing continues to
providing safe, patient-centered care and collaborating with others. evolve to meet society’s health care needs.
As a nurse, you (1) offer skilled care to those recovering
PROFESSIONAL NURSING PRACTICE from illness or injury, (2) advocate for patients’ rights, (3)
teach patients to manage their health, (4) support patients and
Domain of Nursing Practice their caregivers at critical times, and (5) help them navigate the
Today, nursing practice consists of a wide variety of roles and complex health care system. You can practice in virtually all
responsibilities necessary to meet society’s health care needs. health care settings and communities. Although many nurses
1
,2 SECTION 1 Concepts in Nursing Practice
times a person needs help to meet these needs, cope success-
fully, or develop their unique potential.
Scope of Nursing Practice
The essential core of nursing practice is to deliver holistic,
patient-centered care. This includes assessment and evaluation,
giving a variety of interventions, patient and caregiver teaching,
and being a member of the interprofessional health care team.
The extent that nurses engage in their scope of practice
depends on their educational preparation, experience, role, and
state law. To enter practice, a nurse must complete an accredited
program and pass the NCLEX-RN, a test that verifies the nurse
has the basic knowledge needed to provide safe care. Entry-level
nurses with associate or baccalaureate degrees are prepared to
Fig. 1.1 Nurses are frontline professionals of health care. (© LightField-
Studios/iStock/Thinkstock.)
function as generalists. At this level, nurses provide direct health
care and focus on ensuring coordinated, comprehensive care to
patients in a variety of settings.
work in acute care facilities, nurses may practice in long-term With experience and continued study, nurses may special-
care, home care, community health, public health centers, ize in a specific practice area. Certification is a formal way for
schools, and ambulatory or outpatient clinics. Wherever you nurses to obtain professional recognition for having exper-
practice, recipients of your care include individuals, families, tise in a specialty area. Many nursing organizations offer cer-
groups, or communities. Nurses work collaboratively with tification in specialty practice. Certification requires a certain
other health care providers to manage the needs of persons amount of clinical experience and successfully passing a test.
and groups. Recertification usually requires ongoing clinical experience and
continuing education. Common nursing specialties include
Definitions of Nursing critical care, women’s health, geriatric, medical-surgical, peri-
Nursing is described as both an art and a science; a heart and a natal, emergency, psychiatric/mental health, and community
mind.1 Well-known definitions of nursing show that the basic health nursing.
themes of caring, health, and illness have existed since Florence More education and experience can prepare nurses for
Nightingale first described nursing. Here are 2 such examples: advanced practice. An advanced practice registered nurse
• Nursing is putting the patient in the best condition for nature (APRN) is a nurse educated at the master’s or doctoral level.
to act (Nightingale).2 They have advanced education in pathophysiology, pharmacol-
• The nurse’s unique function is to aid patients, sick or well, ogy, and health assessment and expertise in a specialized area of
in performing those activities contributing to health or its practice. APRNs include clinical nurse specialists, nurse practi-
recovery (or to peaceful death) that they would perform tioners, nurse midwives, and nurse anesthetists. APRNs play a
unaided if they had the necessary strength, will, or knowl- vital role in the health care delivery system. Besides managing
edge—and to do this in such a way as to help them gain inde- and delivering expert direct patient care, APRNs have roles in
pendence as rapidly as possible (Henderson).3 patient and staff education, leadership, quality improvement,
In 2010, the American Nursing Association (ANA) provided research, and consulting.
a new definition of nursing that reflects the ongoing evolution The doctor of nursing practice (DNP) degree is a practice-
of nursing practice: focused terminal nursing degree. With raising the educa-
tional preparation for APRNs to the doctoral level, nursing
Nursing is the protection, promotion, and optimization
is at the same level as other health professions that have
of health and abilities, prevention of illness and injury,
practice doctorates (pharmacy [PharmD], physical therapy
alleviation of suffering through the diagnosis and treat-
[DPT]). Nurses with a research-focused doctorate (PhD)
ment of human response, and advocacy in the care of
typically work in health care settings as nurse faculty, clinical
individuals, families, communities, and populations.4
experts, researchers, and health care system executives.
Nursing’s View of Humanity Standards of Professional Nursing Practice
In this book, we believe 7 dimensions of wellness contribute to To guide nurses in how to perform professionally, the ANA
health and quality of life: Physical, psychologic, social, spiritual, defined Standards of Professional Nursing Practice. There are
intellectual, career, and environmental. These dimensions are 2 parts, Standards of Practice and Standards of Professional
interrelated and not separate entities. Thus, a problem in one Performance.5 The Standards of Practice describe a competent
dimension may affect one or more of the other dimensions. A level of nursing care based on the nursing process. The Standards
person is in constant interaction with a changing environment. of Professional Performance describe behavioral competencies
A person’s behavior is meaningful and oriented toward fulfilling expected of a nurse. You are following the performance stan-
needs, coping with stress, and developing oneself. However, at dards when you practice ethically and use evidence-based
, CHAPTER 1 Professional Nursing 3
practice. Communicating effectively and staying competent in administrative costs, and more expensive products and treat-
practice are essential. You must be able to work in collaboration ments. Many changes in health care systems that influence nurs-
with other health care team members, patients, and caregivers. ing care delivery are usually in an effort to contain spending and
provide more cost-effective health care delivery.
INFLUENCES ON PROFESSIONAL NURSING The U.S. health system is a mix of public and private, for-
PRACTICE profit and nonprofit insurers, and health care providers. Public
and private insurers set their own cost-sharing structures within
Expanding Knowledge and Technology federal and state regulations. Historically, the most noted event
Ever-changing technology and rapidly expanding clinical related to reimbursement was the establishment of the Medicare
knowledge add to the complexity of health care. The increased prospective payment system (PPS). With PPS, payment for care
treatment, diagnostic, and care options available change care for Medicare patients is based on flat fees determined by the dis-
delivery and extend patients’ lives. Discoveries in genetics are eases and problems treated during the admission. For example,
changing how we think about diseases such as cancer and heart if a patient had a total hip replacement, the hospital receives a
disease. For example, genetic information guides breast cancer set sum of money, such as $45,000, for the patient’s care.
treatment. If a woman has cancer, this information allows for Other managed care systems also use PPS. In health main-
treatment and drug therapy based on genetic makeup. Ethical tenance organizations (HMOs) and preferred provider organi-
dilemmas arise about the use of new scientific knowledge and zations (PPOs), charges are negotiated before delivering care
the disparities that exist in patients’ access to advanced health using fixed reimbursement rates or capitation fees for medical
care. Throughout this book, genetics and ethical/legal boxes care, hospitalization, and other health care services.
highlight expanding knowledge and technology’s impact on Now, quality initiatives have further changed health care
nursing practice. financing. Value-based purchasing programs base payment to
health care providers on their performance on certain quality
Diverse Populations measures. These measures include clinical outcomes, patient
Patient populations are more diverse than ever. People are living safety, patient satisfaction, and the provider’s adherence to evi-
longer, with the number of people with chronic illnesses and dence-based practice. Those who provide quality care at a lower
multiple comorbidities increasing. Unlike those who receive cost may receive more payment.
acute, episodic care, patients with chronic illnesses have complex As part of value-based purchasing, payment for care can be
needs. They see different health care providers over an extended withheld if a patient experiences events such as developing a
period and often move among health care settings. You need to pressure injury during a hospital stay or having something hap-
be able to manage and coordinate care when patients transition pen that is considered preventable (fall-related injury, having
among different settings. wrong-site surgery). This type of event is considered a serious
At the same time, you will be caring for a more culturally and reportable event (SRE). SREs are discussed later in this chapter.
ethnically diverse population. When delivering care, you must
consider the patient’s and caregiver’s cultural beliefs and values. Health Policy
Immigrants, particularly undocumented immigrants, often lack Legislation has serious implications for health care delivery and
the resources necessary to access health care. Inability to pay for nursing practice. The Affordable Care Act (ACA) was the most
health care is related to a tendency to delay seeking care, result- important health care legislation since the creation of Medicare
ing in more serious illnesses at the time of diagnosis. Boxes in 1965. The ACA triggered changes throughout the health care
throughout this book emphasize the influence of such factors as system. The ACA’s main goal was to increase access to health
gender, culture, and ethnicity on nursing practice. care. The ACA created new health care delivery and payment
models that emphasized teamwork, care coordination, and
Consumerism quality care.
Many patients today want to be more engaged in their health The ACA encourages the creation of accountable care orga-
care. They want more control over their health care and expect nizations (ACOs). ACOs are groups of physicians, hospitals,
high-quality, coordinated, and financially reasonable care. and health care providers who unite to coordinate care for
Health information is readily available. Many patients are very Medicare patients. The goal of an ACO is to see that patients,
knowledgeable about their health and seek information about especially the chronically ill, get the right care at the right time
health problems and health care from media and Internet while avoiding duplicate services and preventing errors. As a
sources. They gather information so that they can have a voice in nurse, you must take a leadership role in creating health care
making decisions about their health care. As a nurse, you must systems that provide safe, quality, patient-centered care.
be able to help patients access, interpret, and use safe health care
information (Fig. 1.2). Professional Nursing Organizations
The ANA is the primary professional nursing organization.
Health Care Financing There are many professional specialty organizations, such as
High health care costs are a growing problem. There are many the American Association of Critical-Care Nurses (AACN),
reasons for the continued increase in costs. These include the National Association of Orthopedic Nurses (NAON), and
aging population, increased prescription medication use, Oncology Nursing Society (ONS). Professional organizations
1
Professional Nursing
Mariann M. Harding
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Care Competencies Clinical Judgment
Leadership Professional Identity
LEARNING OUTCOMES
1. Describe the domain and definition of professional nursing 5. Explore the role of the professional nurse in delegating
practice. care to licensed practical/vocational nurses and assistive
2. Compare the different scopes of practice available to personnel.
professional nurses. 6. Discuss the role of integrating safety and quality
3. Describe the role of clinical judgment skills and using a improvement processes into nursing practice.
clinical practice framework to provide patient-centered 7. Evaluate the role of informatics and health care technology
care. in nursing practice.
4. Apply the SBAR procedure and effective communication 8. Apply concepts of evidence-based practice to nursing
techniques in the clinical setting. practice.
KEY TERMS
advanced practice registered nurse (APRN) interprofessional team
clinical pathways nursing
clinical judgment nursing process
delegation patient handoff
electronic health records (EHRs) SBAR (Situation-Background-Assessment-Recommendation)
evidence-based practice (EBP) serious reportable event (SRE)
failure to rescue telehealth
This chapter presents an overview of professional nursing practice, You have never been more important to health care than you
discussing the wide variety of roles and responsibilities nurses fulfill are today. As a nurse, you are at the forefront of patient care (Fig.
to meet society’s health care needs. This overview includes the core 1.1). Beyond nursing’s reputation for compassion and dedica-
abilities that are part of competent nursing practice. These include tion lies a highly specialized profession.1 Nursing continues to
providing safe, patient-centered care and collaborating with others. evolve to meet society’s health care needs.
As a nurse, you (1) offer skilled care to those recovering
PROFESSIONAL NURSING PRACTICE from illness or injury, (2) advocate for patients’ rights, (3)
teach patients to manage their health, (4) support patients and
Domain of Nursing Practice their caregivers at critical times, and (5) help them navigate the
Today, nursing practice consists of a wide variety of roles and complex health care system. You can practice in virtually all
responsibilities necessary to meet society’s health care needs. health care settings and communities. Although many nurses
1
,2 SECTION 1 Concepts in Nursing Practice
times a person needs help to meet these needs, cope success-
fully, or develop their unique potential.
Scope of Nursing Practice
The essential core of nursing practice is to deliver holistic,
patient-centered care. This includes assessment and evaluation,
giving a variety of interventions, patient and caregiver teaching,
and being a member of the interprofessional health care team.
The extent that nurses engage in their scope of practice
depends on their educational preparation, experience, role, and
state law. To enter practice, a nurse must complete an accredited
program and pass the NCLEX-RN, a test that verifies the nurse
has the basic knowledge needed to provide safe care. Entry-level
nurses with associate or baccalaureate degrees are prepared to
Fig. 1.1 Nurses are frontline professionals of health care. (© LightField-
Studios/iStock/Thinkstock.)
function as generalists. At this level, nurses provide direct health
care and focus on ensuring coordinated, comprehensive care to
patients in a variety of settings.
work in acute care facilities, nurses may practice in long-term With experience and continued study, nurses may special-
care, home care, community health, public health centers, ize in a specific practice area. Certification is a formal way for
schools, and ambulatory or outpatient clinics. Wherever you nurses to obtain professional recognition for having exper-
practice, recipients of your care include individuals, families, tise in a specialty area. Many nursing organizations offer cer-
groups, or communities. Nurses work collaboratively with tification in specialty practice. Certification requires a certain
other health care providers to manage the needs of persons amount of clinical experience and successfully passing a test.
and groups. Recertification usually requires ongoing clinical experience and
continuing education. Common nursing specialties include
Definitions of Nursing critical care, women’s health, geriatric, medical-surgical, peri-
Nursing is described as both an art and a science; a heart and a natal, emergency, psychiatric/mental health, and community
mind.1 Well-known definitions of nursing show that the basic health nursing.
themes of caring, health, and illness have existed since Florence More education and experience can prepare nurses for
Nightingale first described nursing. Here are 2 such examples: advanced practice. An advanced practice registered nurse
• Nursing is putting the patient in the best condition for nature (APRN) is a nurse educated at the master’s or doctoral level.
to act (Nightingale).2 They have advanced education in pathophysiology, pharmacol-
• The nurse’s unique function is to aid patients, sick or well, ogy, and health assessment and expertise in a specialized area of
in performing those activities contributing to health or its practice. APRNs include clinical nurse specialists, nurse practi-
recovery (or to peaceful death) that they would perform tioners, nurse midwives, and nurse anesthetists. APRNs play a
unaided if they had the necessary strength, will, or knowl- vital role in the health care delivery system. Besides managing
edge—and to do this in such a way as to help them gain inde- and delivering expert direct patient care, APRNs have roles in
pendence as rapidly as possible (Henderson).3 patient and staff education, leadership, quality improvement,
In 2010, the American Nursing Association (ANA) provided research, and consulting.
a new definition of nursing that reflects the ongoing evolution The doctor of nursing practice (DNP) degree is a practice-
of nursing practice: focused terminal nursing degree. With raising the educa-
tional preparation for APRNs to the doctoral level, nursing
Nursing is the protection, promotion, and optimization
is at the same level as other health professions that have
of health and abilities, prevention of illness and injury,
practice doctorates (pharmacy [PharmD], physical therapy
alleviation of suffering through the diagnosis and treat-
[DPT]). Nurses with a research-focused doctorate (PhD)
ment of human response, and advocacy in the care of
typically work in health care settings as nurse faculty, clinical
individuals, families, communities, and populations.4
experts, researchers, and health care system executives.
Nursing’s View of Humanity Standards of Professional Nursing Practice
In this book, we believe 7 dimensions of wellness contribute to To guide nurses in how to perform professionally, the ANA
health and quality of life: Physical, psychologic, social, spiritual, defined Standards of Professional Nursing Practice. There are
intellectual, career, and environmental. These dimensions are 2 parts, Standards of Practice and Standards of Professional
interrelated and not separate entities. Thus, a problem in one Performance.5 The Standards of Practice describe a competent
dimension may affect one or more of the other dimensions. A level of nursing care based on the nursing process. The Standards
person is in constant interaction with a changing environment. of Professional Performance describe behavioral competencies
A person’s behavior is meaningful and oriented toward fulfilling expected of a nurse. You are following the performance stan-
needs, coping with stress, and developing oneself. However, at dards when you practice ethically and use evidence-based
, CHAPTER 1 Professional Nursing 3
practice. Communicating effectively and staying competent in administrative costs, and more expensive products and treat-
practice are essential. You must be able to work in collaboration ments. Many changes in health care systems that influence nurs-
with other health care team members, patients, and caregivers. ing care delivery are usually in an effort to contain spending and
provide more cost-effective health care delivery.
INFLUENCES ON PROFESSIONAL NURSING The U.S. health system is a mix of public and private, for-
PRACTICE profit and nonprofit insurers, and health care providers. Public
and private insurers set their own cost-sharing structures within
Expanding Knowledge and Technology federal and state regulations. Historically, the most noted event
Ever-changing technology and rapidly expanding clinical related to reimbursement was the establishment of the Medicare
knowledge add to the complexity of health care. The increased prospective payment system (PPS). With PPS, payment for care
treatment, diagnostic, and care options available change care for Medicare patients is based on flat fees determined by the dis-
delivery and extend patients’ lives. Discoveries in genetics are eases and problems treated during the admission. For example,
changing how we think about diseases such as cancer and heart if a patient had a total hip replacement, the hospital receives a
disease. For example, genetic information guides breast cancer set sum of money, such as $45,000, for the patient’s care.
treatment. If a woman has cancer, this information allows for Other managed care systems also use PPS. In health main-
treatment and drug therapy based on genetic makeup. Ethical tenance organizations (HMOs) and preferred provider organi-
dilemmas arise about the use of new scientific knowledge and zations (PPOs), charges are negotiated before delivering care
the disparities that exist in patients’ access to advanced health using fixed reimbursement rates or capitation fees for medical
care. Throughout this book, genetics and ethical/legal boxes care, hospitalization, and other health care services.
highlight expanding knowledge and technology’s impact on Now, quality initiatives have further changed health care
nursing practice. financing. Value-based purchasing programs base payment to
health care providers on their performance on certain quality
Diverse Populations measures. These measures include clinical outcomes, patient
Patient populations are more diverse than ever. People are living safety, patient satisfaction, and the provider’s adherence to evi-
longer, with the number of people with chronic illnesses and dence-based practice. Those who provide quality care at a lower
multiple comorbidities increasing. Unlike those who receive cost may receive more payment.
acute, episodic care, patients with chronic illnesses have complex As part of value-based purchasing, payment for care can be
needs. They see different health care providers over an extended withheld if a patient experiences events such as developing a
period and often move among health care settings. You need to pressure injury during a hospital stay or having something hap-
be able to manage and coordinate care when patients transition pen that is considered preventable (fall-related injury, having
among different settings. wrong-site surgery). This type of event is considered a serious
At the same time, you will be caring for a more culturally and reportable event (SRE). SREs are discussed later in this chapter.
ethnically diverse population. When delivering care, you must
consider the patient’s and caregiver’s cultural beliefs and values. Health Policy
Immigrants, particularly undocumented immigrants, often lack Legislation has serious implications for health care delivery and
the resources necessary to access health care. Inability to pay for nursing practice. The Affordable Care Act (ACA) was the most
health care is related to a tendency to delay seeking care, result- important health care legislation since the creation of Medicare
ing in more serious illnesses at the time of diagnosis. Boxes in 1965. The ACA triggered changes throughout the health care
throughout this book emphasize the influence of such factors as system. The ACA’s main goal was to increase access to health
gender, culture, and ethnicity on nursing practice. care. The ACA created new health care delivery and payment
models that emphasized teamwork, care coordination, and
Consumerism quality care.
Many patients today want to be more engaged in their health The ACA encourages the creation of accountable care orga-
care. They want more control over their health care and expect nizations (ACOs). ACOs are groups of physicians, hospitals,
high-quality, coordinated, and financially reasonable care. and health care providers who unite to coordinate care for
Health information is readily available. Many patients are very Medicare patients. The goal of an ACO is to see that patients,
knowledgeable about their health and seek information about especially the chronically ill, get the right care at the right time
health problems and health care from media and Internet while avoiding duplicate services and preventing errors. As a
sources. They gather information so that they can have a voice in nurse, you must take a leadership role in creating health care
making decisions about their health care. As a nurse, you must systems that provide safe, quality, patient-centered care.
be able to help patients access, interpret, and use safe health care
information (Fig. 1.2). Professional Nursing Organizations
The ANA is the primary professional nursing organization.
Health Care Financing There are many professional specialty organizations, such as
High health care costs are a growing problem. There are many the American Association of Critical-Care Nurses (AACN),
reasons for the continued increase in costs. These include the National Association of Orthopedic Nurses (NAON), and
aging population, increased prescription medication use, Oncology Nursing Society (ONS). Professional organizations
