ANA standard
Instructions:
Review the ANA Standards document. Focus on the Standards of Professional Performance.
Choose two of the 11 standards that captures your attention.
Search for a relevant journal article which explains or discusses the importance of this standard
Topics and prompts to include
1. Introduction
a. Announce the chosen Standard of Professional Performance using the number and name from the document.
b. Briefly define the Standard.
2. Journal Article
a. Provide the title, author, date of publication, and where you found the article.
b. Briefly summarize the article and explain how the article connects professional nursing to the chosen Standard.
3. Commentary
a. What does this Standard add to your understanding of the nursing profession?
b. Why do you think the Standard is relevant to nursing today?
c. Provide a concrete example of how you can (and will) incorporate this Standard into your nursing practice.
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References
Moss, E., Seifert, P. C., & OSullivan, A. (2016). Registered Nurses as Interprofessional Collaborative Partners:
Creating Value-Based Outcomes. Online Journal of Issues in Nursing, 21(3), 6. https://doi-
org.resu.idm.oclc.org/10.3912/OJIN.Vol21No03Man04
Registered Nurses as Interprofessional Collaborative Partners: Creating Value-Based Outcomes
State-specific nurse practice acts, a defined registered nurse (RN) scope of practice, and nurse-led
initiatives prepare nurses to lead in a meaningful and ethical way within the professional practice setting.
However, barriers still exist that challenge the full RN scope of practice. One of these barriers is
insufficient interprofessional collaboration among healthcare providers from multiple disciplines. We will
briefly discuss the RN scope of practice and describe several evidence-based transition to practice
programs and activities that are effectively helping to minimize these barriers. The article will also
consider opportunities for interprofessional collaboration for RNs to implement evidence-based
programs to support transition to practice, create interprofessional collaborative environments, and care
for patients in a culturally competent way to minimize healthcare disparities. We conclude by offering
recommendations to enhance interprofessional collaboration.
Key Words: interprofessional collaboratiion; value-based outcomes; transition to practice; diversity;
culturally competent care; workforce data; nurse led initiatives; scope of practice
Members of the American Nurses Association (ANA) Professional Issues Panel (Panel) Steering
Committee, Barriers to RN Scope of Practice, recently worked to identify barriers that prevent RNs from
working to the full extent of their education and training. This Panel both explored the basis for barriers,
and subsequently developed appropriate recommendations. Panel findings were divided into four key
roles of RNs in the healthcare delivery system, specifically RN as professional, RN as advocate, RN as
innovator, and RN as collaborative leader. This OJIN topic considers barriers to RN scope of practice
from the perspective of each of these roles.
One barrier is insufficient interprofessional collaboration among healthcare providers from multiple
disciplines.One barrier is insufficient interprofessional collaboration among healthcare providers from
multiple disciplines. Interprofessional collaboration is the collective involvement of various professional
healthcare providers working with patients, families, caregivers, and communities to consider and
communicate each other’s unique perspective in delivering the highest quality of care (Sullivan et al.,
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2015). As leaders, all RNs are, or should be, invested as interprofessional collaborative partners in the
creation of outcomes of value for the patients, families, and the community they serve. We will discuss
several evidence-based transition to practice programs and activities that are effectively helping to
minimize this and other barriers. The article will also consider opportunities for interprofessional
collaboration for RNs to implement evidence-based programs to support transition to practice, create
interprofessional collaborative environments, and care for patients in a culturally competent way to
minimize healthcare disparities. We conclude by offering recommendations to enhance interprofessional
collaboration.
RN Scope of Practice
Nursing has ranked number one in ethics and honesty, according to Gallup polls, for 16 of the past 17
years (Gallup, 2014). Registered nurses (RNs) advocate as they contribute to care of families,
individuals, communities, and populations. Care by professional nurses helps to protect, promote, and
optimize health and prevent illness and injury through the diagnosis and treatment of human response
(ANA, 2016). RN practice is bound by a set of rules and regulations, known as nurse practice acts,
which defines practice within the scope of the profession. These practice acts require licensed
professional nurses to demonstrate a minimum requisite education and/or training and competence to
provide services within the scope of practice (Russell, 2012).
The scope of nursing practice describes the “who,” “what,” “when,” “where,” “why, and “how” of nursing
practice. The scope of nursing practice describes the “who,” “what,” “when,” “where,” “why, and “how” of
nursing practice. All actively licensed and advanced practiced RNs describe “who” practices nursing.
The definition of nursing describes a succinct characterization of the “what” of nursing. Nursing occurs
“when” there is a nursing need for leadership, advocacy, caring, knowledge, or education anywhere.
The “why” considers reasons why the nursing profession has ranked number one in ethics and honesty
for 16 of the past 17 years. RNs respond to the changing needs of society to achieve positive healthcare
outcomes in keeping with nursing’s social contract with society. The “how” is characterized as the ways,
means, and methods that RNs use to practice professionally (ANA, 2015a; ANA, 2015b).
all professional nurses should be implementing evidence-based programs to support transition to
practice Guiding documents in the profession prepare nurses to lead within the professional practice
setting and the profession itself. Specific competencies establish actions required of RNs to influence
policy to promote health; mentor colleagues for the advancement of nursing practice and the profession;
encourage innovation in practice and role performance; and influence decision-making. Individual RNs
must actively take responsibility to seek opportunities for developing leadership skills, as recommended
by the Institute of Medicine (IOM; ANA, 2015b; IOM, 2015). Opportunities must exist for RNs to lead and
diffuse collaborative improvement efforts and to lead changes to advance health (IOM, 2015). As the
nursing profession moves forward in the 21st century, all professional nurses should be implementing
evidence-based programs to support transition to practice and creating interprofessional collaborative
environments. In addition, nurses should identify optimal opportunities to provide culturally competent
care for patients; minimize healthcare disparities from a nursing care perspective; and develop a
workforce reflecting the communities served.
Barriers to Full Scope of Practice
A common reason [for barriers] is differences among and between the states in their regulatory
language for RNs Barriers related to RN practice at the full scope stem from various sources. A
common reason is differences among and between the states in their regulatory language for RNs
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(states individually regulate practice). These differences may be subtle or obvious. In each state, there
is a unique nurse practice act (NPA) which serves as the definition of professional nursing practice. The
NPA is supported by a board of nursing (BON) consisting of members appointed by an elected official
(governor), a legislative body, or persons elected by the population at large (Russell, 2012).
The restriction of nursing practice by state regulation and subsequent organizational limits are
highlighted in the ANA model of professional nursing practice regulation (ANA, 2015a; Fowler 2015).
Nursing practice begins with a professional statement of practice and code of ethics to support decision
making, but these core professional nursing tenets are then subjected to interpretation by each state,
territory, and district. They become differing scopes of practice for RNs, based solely on geographic
location. State-defined scopes of practice for RNs may be further restricted at the organizational level
through enactment of policy and procedure.
Nurse leaders must decide on a uniform scope of practice that focuses on knowledge and is grounded
in evidence. Nurse leaders must decide on a uniform scope of practice that focuses on knowledge and
is grounded in evidence. The growth in participation in the Nurse Licensure Compact that has grown to
include 25 states represents a movement in the direction of uniformity of practice (NCSBN, 2012), yet
RNs must still adhere to individual state restrictions. Essentially, a nurse traveling a short geographic
distance from one state to another may have a change in scope of practice unrelated to scientific
evidence or individual skill. One agency, the Department of Veterans Affairs (VA) is an exemplar in its
demonstration of uniformity of practice across states. RNs may seek employment at any VA location in
one of all 50 states, the District of Columbia, and Puerto Rico and maintain only one active unrestricted
state license (U.S. Department of Veterans Affairs, 2012).
One example of interprofessional collaboration is illustrated by a joint meeting of the Virginia BON and
the Board of Medicine in the 1970s (Joint Committee, 1976). This enabled RNs in the operating room to
serve as surgical first assistants and enhance their clinical leadership skills, thereby foreshadowing both
expanded and advanced practice pathways for RNs. Whether nurses are practicing in a hospice or a
hospital, it is important to recognize not only the intellectual basis of nursing, but also the importance of
the technical skills that, properly managed and employed, make a significant impact on patient
outcomes.
Differences in the entry level of RN practice and the related educational preparation (e.g., diploma,
associate degree, or BSN) to become an RN are also relevant to any discussion of barriers concerning
scope of practice. Educational curriculum and education accreditation criteria must focus on a
knowledge-based scope of practice based on baccalaureate level preparation. Nursing leaders must be
the ones to define professional scope of practice for those RNs graduating from an academic,
knowledge-based, educational program.
RNs must be in key organizational leadership and decision-making roles to reduce restrictions to
nursing practice. The nursing profession scope of practice should address RNs as team leaders and
focus on nursing as a holistic clinical discipline (Folan et al., 2012). RNs must be in key organizational
leadership and decision-making roles to reduce restrictions to nursing practice. Organizational
leadership includes practice-based organizations (e.g., healthcare), federal entities (e.g., Centers for
Medicare & Medicaid Services [CMS]), and private insurers. Organizational limits to nursing practice
place unnecessary restrictions on RNs and limit availability of innovative and creative solutions to many
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of the problems encountered, understood, and resolved by RNs on a daily basis. However, before
nurses can serve in leadership roles, they must achieve a successful transition to practice.
Transition to Practice
Socialization of nursing students is important to prepare graduates for interacting with a variety of
professional and nonprofessional individuals in the healthcare setting. Socialization of nursing students
is important to prepare graduates for interacting with a variety of professional and nonprofessional
individuals in the healthcare setting. However, the emphasis in nursing education must alter from largely
socialization among nurses to formation of professional nurses collaborating with others; specifically,
from imitating or copying past practices to being a reformed process of interprofessional collaboration.
Using dated approaches to nursing education and failure to adopt approaches when evidence has
demonstrated significant successes is a barrier to achieving the goal of interprofessional collaboration
(Benner, Sutphen, Leonard, & Day, 2010).
The majority of healthcare disciplines are educated at the baccalaureate level or higher. A 2-year
curriculum, no matter how exemplary (and many are) cannot teach all components needed to prepare
RNs to assume needed leadership positions. Over 50% of new RN graduates in the United States are
prepared at the diploma or associate-degree level (Raines & Taglaireni, 2008) Integration into pre-
practice level educational courses with other providers (e.g., social workers, medical or pharmacy
students) is difficult, as students in such disciplines are not educated at community college campuses
(American Association of Colleges of Nursing [AACN], 2008, n.d; Benner et al., 2010). The variety in
nursing educational pathways for licensure contributes to graduates with diverse competencies.
Because of this educational diversity, new graduates arrive at the workplace with widely differing abilities
and skills that create additional challenges in the workplace.
Transition Programs
There are a variety of transition to practice programs, with several basic considerations integral to all
programs. One important consideration is reflected in the Dreyfus’ Model of Skill Acquisition (Dreyfus,
1982). Benner (2001) adapted and applied this model to her concept of contextual learning. According
to this model, a new graduate transitions from advanced beginner to competent practitioner, which
enables the nurse to acquire:
* Improved organizational ability and technical skills
* Greater focus on managing the patient condition as opposed to accomplishing “tasks”
* Ability to identify significant clinical signs and symptoms
* Movement toward involvement and responsibility
a successful transition to practice has important benefits to patients and families. The American
Organization of Nurse Executives (AONE; 2010) guiding principles address the role of preceptors,
mentors, and coaches. These principles emphasize that a successful transition to practice has important
benefits to patients and families. The AONE guiding principles note that commitment to transition of
newly licensed nurses into practice occurs across all organizational levels, including senior leadership
and nursing leadership.
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New graduate transition programs have been developed in response to beliefs that new graduate
nurses were ill prepared for practice in the highly acute, complex, and rapid-paced hospital environment
where most nurses are employed (Culley et al., 2012; Lofmark, Smide, & Wikblad, 2006). Health
systems were further motivated by costs related to high turnover rates for new graduate nurses in the
first two years of employment (Hayes et al., 2012; Trepanier, Early, Ulrich, & Cherry, 2012).
Transition programs build upon traditional orientation programs, which last from three days to six weeks
(Theisen & Sandau, 2013). Traditional orientation focuses on skill acquisition, information systems, and
specific organizational routines and policies. Retention, organizational, and individual outcomes from
these traditional programs are often compared to outcomes of more comprehensive transition programs.
Three specific examples of expanded transition programs are described below.
Nurse residency. National healthcare thought leaders called for the implementation of nurse residencies
to reduce new nurse stress, practice errors, and turnover (Benner et al., 2010; IOM, 2011; Joint
Commission, 2002). However, existing programs vary in content, length, and other essential elements
(Barnett, Minnick, & Norman, 2014; Spector et al., 2015). Adoption of residency programs by health
systems has been slow, although there is evidence that the rate of uptake is increasing (AACN, 2008).
According to the National Council of State Boards of Nursing (NCSBN, 2014), it is the responsibility of
healthcare systems to assure new RNs have experiential learning in the specialties where they are
employed. Thus, customized transition programs are required based on practice specialty.
Recent efforts by health systems and academic stakeholders have produced evidence-based,
programmatic transition programs. Recent efforts by health systems and academic stakeholders have
produced evidence-based, programmatic transition programs. The University Health System
Consortium (UHC) and American Association of Colleges of Nursing (AACN) Nurse Residency
Program, Transition to Practice (TTP), was developed collaboratively by academic medical centers and
baccalaureate schools of nursing (University HealthSystem Consortium [UHC], 2008). With funding from
the Robert Wood Johnson Foundation (RWJF), a comprehensive evaluation plan was implemented to
identify outcomes of the first two program phases. Program outcomes demonstrated positive
improvements on retention rates, nurse confidence, competence, organization, prioritization,
communication, leadership, and decreased perceived stress (UHC, 2008). The UHC/AACN team also
developed a set of standards for accreditation of post-BSN nursing residencies. Accreditation is a
criterion for reimbursement of residency costs by CMS. Furthermore, standards and accreditation are
critical mechanisms for improving residency rigor and standardization.
Both TTP and established programs resulted in new graduates having higher overall competence, less
stress, more job satisfaction, and fewer turnovers (Spector et al., 2015). In the limited programs, new
graduates were more likely to report higher job stress and less job satisfaction, and were twice as likely
to leave their position within the first two years of practice (NCSBN, 2014).
NCSBN (2014) offers a TTP toolkit that includes the following e-learning modules: patient-centered
care; communication and teamwork; evidence-based practice; quality improvement; informatics; and
preceptor training. Another program with goals similar to those of the TTP of UHC/AACN was developed
by the Department of Veteran Affairs, Veterans Health Administration (VHA, 2011). The VHA designed a
12-month residency program with goals similar to the UHC/AACN program. The VHA also formulated
strategies to combat the high cost of new RN turnover. Teaching methodologies included classroom
education, preceptor clinical experiences, monthly meetings, group clinical debriefings, one-on-one
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mentoring, and an evidence-based project (VHA, 2011). The VHA pilot resulted in a 100% retention rate
across facilities and formed the basis for a national launch. Reviews found that programs were effective
when they spanned the first year of practice. Preceptorship was highlighted as an important component
of program success (Spector et al., 2015).
barriers can exist when RNs who might serve as preceptors come from different educational
backgrounds. Preceptorship. Preceptorships have been a common transition program for new RN staff.
Despite frequent use of preceptors, and evidence that this model provides an important component of
success (Spector et al., 2015), challenges still exist for both new staff RNs and preceptors. For
example, barriers can exist when RNs who might serve as preceptors come from different educational
backgrounds. Expecting clinical RNs to have the competencies of skilled educators may not be a reality
(Hautala, Saylor, & O’Leary-Kelley, 2007).
Student nurse externship. Nurse externships allow nursing students an opportunity to experience real-
world clinical practice over a 3 to 12-week period using a nurse preceptor-student model (Friday, Zoller,
Hollerbach, Jones, & Knofczynski, 2015). The major goals are to attract student nurses for employment
upon graduation, reduce costs for employee recruitment, and improve new graduate nurse performance
and retention. However, outcomes have been mixed. Both retention and professional satisfaction of new
graduate nurses who participated in externships were slightly improved over nonparticipants in several
studies (Cantrell & Browne, 2006; Friday et al., 2015; Steen, Gould, Raingruber, & Hill, 2011), although
in one study, 2-year retention was markedly less than that of new graduates who participated in
residency or preceptor programs (Salt, Cummings, & Profestto-McGrath, 2008). Numerous studies have
indicated minimal or no improvement in ease of transition to practice, professionalism, and job
performance in new graduate nurses who completed externship programs (Cantrell & Browne, 2006;
Friday et al., 2015; Steen et al., 2011).
continued attention to program development can provide experiences to maximize opportunities for
interprofessional collaboration to create strong nurse leaders at every level of care. In sum, several
transition to practice programs have been in place and have demonstrated some positive outcomes.
However, continued attention to program development can provide experiences to maximize
opportunities for interprofessional collaboration to create strong nurse leaders at every level of care.
Healthy Work Environments for Nursing Practice A healthy work environment is one that is safe,
empowering, and satisfying. It is not merely the absence of real and perceived physical or emotional
threats to health, but a place of physical, mental, and social well-being, supporting optimal health and
safety. Healthcare workers have a fivefold risk of experiencing workplace violence when compared to
the overall workforce (National Institute for Occupational Safety and Health, 2013). The presence of
overt and covert workplace violence, bullying, and incivility significantly impacts both the individual nurse
and the overall work environment, including increased time away from work, higher turnover rates
among RNs and other team members, and suboptimal patient outcomes.
all leaders, managers, healthcare workers, and ancillary staff have responsibility as part of the
interprofessional team to perform with a sense of professionalism, accountability, transparency,
involvement, efficiency, and effectiveness. A culture of safety is paramount and must include everyone,
including those who are transitioning into practice. In such a culture, all leaders, managers, healthcare
workers, and ancillary staff have responsibility as part of the interprofessional team to perform with a
sense of professionalism, accountability, transparency, involvement, efficiency, and effectiveness. All
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must be mindful of the health and safety of both the healthcare consumer and the healthcare worker in
any setting providing care, offering a sense of safety, respect, and empowerment to and for all persons
(ANA, 2015a). To do this with intent, genuine interprofessional collaboration that includes all levels of
nursing practice must be evident in daily interactions. In the next section, we will consider opportunities
for interprofessional collaboration specifically as they might apply to barriers to full RN scope of practice.
Opportunities for Interprofessional Collaboration
The landmark report, The Future of Nursing: Leading Change, Advancing Health (IOM, 2011), focused
on the rapid changes occurring in healthcare and the critical role of RNs in developing policy,
implementing changes, providing and coordinating patient care, and measuring healthcare
improvements.
After the release of the 2011 IOM report, the Robert Wood Johnson Foundation (RWJF), in collaboration
with Campaign for Action (2015), initiated a campaign to assist in the explication and implementation of
the report recommendations. The RWJF also asked the IOM to examine changes and progress made
after releasing of their report. The followup report (IOM, 2015) illustrated both significant progress and
additional considerations for further study.
AACN, along with five other organizations, established the Interprofessional Education Collaborative
(IPEC), which is committed to advancing interprofessional learning experiences and promoting team-
based care. The IPEC mission is to ensure the current and new health professionals are proficient in
competencies for community-oriented and population-oriented, patient-centered, collaborative,
interprofessional practice (Interprofessional Education Collaborative, 2016).
In both the 2011 and 2015 IOM reports, considerable focus was placed on the importance of
interprofessional collaboration and the valuable abilities of RNs to collaborate with patients, other
clinicians, educators, and researchers. Targeted areas recommended for greater attention included:
* Removing barriers to practice and care
* Transforming education
* Collaborating and leading
* Promoting diversity
* Improving data
Removing Barriers to Practice and Care
collaborative practice models are not limited to APRNs Although much emphasis in the IOM 2011
report focused on advanced practice registered nurses (APRNs), collaborative practice models are not
limited to APRNs, and the IOM stresses that “all health professionals” (IOM, 2015, p. 2) can improve
both quality and satisfaction. An associated recommendation stresses the importance of working with
other colleagues and groups (e.g., policy makers, elected officials, professional organizations, and
community groups). Engaging colleagues and assisting them to understand the benefits of expanding
RNs’ scope of practice supports greater opportunities for RNs to initiate and lead innovative
improvements in healthcare.
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Transforming Education
Encouraging lifelong learning and obtaining higher levels of education were critical recommendations of
the future of nursing report (IOM, 2011). Additionally, the complexity of the evolving healthcare system
necessitates learning about new systems and procedures and incorporating new information and
knowledge into the practice arena. RNs seeking to expand their education can benefit from programs
that support not only obtaining a BSN but also eventually pursuing masters and doctoral degrees.
Nurse residency programs are designed to build on baccalaureate education. General goals of
residency programs (Barnett et al., 2014; Spector et al., 2015) include:
* Reduce medication errors
* Minimize turnover and stress-induced burnout
* Ease adjustment into clinical practice
* Improve job satisfaction
* Increase nurse confidence
* Improve critical thinking
* Develop care coordination and patient-centered care competencies and models
In this section we discuss several themes related to the IOM call (2011; 2015) for interprofessional
collaboration skills for all RNs to further enhance full scope of practice.
Collaboration and Leadership
RNs provide a broad and deep knowledge and experience related to needs of healthcare systems in
general, and patients in particular. RNs interact with physicians, nurse colleagues, technologists,
administrators, researchers, regulators, accrediting representatives, and others who have an impact on
patient and community outcomes. In addition to interacting with others within the healthcare system,
RNs contribute to the development, implementation, and ongoing improvements in processes and
products such as telenursing (e.g., e-ICUs) and electronic health records (EHRs). Connecting with
influential leaders, expanding colleague networks (in both the work setting and national arena), being a
good listener, clearly articulating idea(s), earning others’ trust (i.e., being accountable, keeping
promises, and respecting confidences), and empowering others are some recommendations described
by Sherman (2015) to boost individual level RN scope of influence.
Trossman (2015) described the importance of collaboration to develop an EHR. In addition to clinical
colleagues, RNs work with information technologists, vendors, and nurse informaticists to develop a
health record that promotes accurate documentation, and contributes significantly to greater ease and
efficiency to document RN care. For example, a nurse informaticist observing RN documentation
processes identified a variety of complicated and unnecessary steps: numerous mouse clicks, scrolling
through multiple computer screens, a prolonged period of documentation, and documentation of
information largely of use to other departments rather than patients under the nurse’s care.
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Strong, collaborative interprofessional teams enable members to embrace patient care policies and
protocols that are team-based and patient-centered. Strong, collaborative interprofessional teams
enable members to embrace patient care policies and protocols that are team-based and patient-
centered. RNs are excellent coordinators able to interact effectively with an intellectually diverse
population of physicians, technologists, administrators, patients, and family members. This ability to
RNs can be excellent coordinators able to interact effectively with an intellectually diverse population of
physicians; technologists; administrators; patients and family members. This ability to communicate with
individuals from various backgrounds, with different goals and responsibilities, is especially valuable
within the complex healthcare environment.
Collaborative efforts between RNs and physicians at multiple levels can offer additional opportunities
for RNs to lead and influence process improvement and improved outcomes. Collaborative efforts
between RNs and physicians at multiple levels (e.g., national, regional, local patient setting) can offer
additional opportunities for RNs to lead and influence process improvement and improved outcomes.
Whether professional organizational representatives from nursing (e.g., ANA) or medicine (e.g.,
American Medical Association) or academic partnerships between and among different schools,
creators of policy initiatives can feature and incorporate contributions of RNs (AONE, 2012). The AONE
(2012) and AACN (n.d.) developed guiding principles for academic/practice partnerships. Such
relationships, whether illustrated by RNs serving on b
