nursing framework in advanced nursing practices

TIME OBJECTIVES CONTENT TEACHERS
ACTIVITY
LEARNERS
ACTIVITY
AV AIDS EVALUATION
 FRAMEWORK,SCOPE ANDTRENDS
Framework:Introduction:
Societ
yanditshealthcareneedalwaysevolving.Asaresult,healthcarefaces
manychallenges,includingrisingcosts,shortageofprofessionals,an
agingpopulation,theintroductionofnewtechnologyanddifficulties
withaccesstocare.Thedemandforcollaborative,innovativeclinical
practitionerstoactasleadersinhealthcarehasneverbeenstronger.Nu
rsesinadvancednursingpracticearewellpositionedtorespondtothe
evolutionofhealthcare.Inparticularadvancednursingplaysakeyroll
inmeetingthehealthneeds.Bybuildingthenursingknowledge,adva
ncingthenursingprofessionandcontributingto a sustained
andeffective health-care system.
DefinitionofNursing Practice:
Advance
dnursingpracticeisanumbrellatermdescribinganadvancedlevelof
clinicalnursingpracticethatmaximizestheuseofgraduateeducation
alprepartion,indepthnursingknowledge&expertiseinmeetingtheh
ealthneedsoftheindividuals,families,groups,communities&popul
ations.It involves:
 Analyzing&synthesizingknowledge.
 Understanding,interpreting &applyingnursingtheory&
research.
 Developing&advancing nursingknowledge&the professionas
thewhole.
Characteristics ofNursing Practice:
I
nadvancednursingpractice,nursesbuildontheirexpertiseinaspecia
lityarea,integrating and

consistentlydisplayingthefollowingfeatures and characteristics:
 Provision of effective and efficientcare,deliveredwith a
highdegree ofautonomy,

 Demonstrationofleadershipandinitiationofchangetoimproveclie
nt,organizationandsystem outcomes.
 Deliberate,purposefulandintegrateduseofin-
depthnursingknowledge,researchandclinical expertise.

 Depthandbreadthofknowledgethatdrawsonawiderangeofstrateg
iestomeettheneeds of clients and to improveaccess to and
qualityof care.

 Abilitytoexplainandapplythetheoretical,empirical,ethicalandex
perientialfoundations of nursingpractice.
 Understanding,developmentanddissemination of evidence-
based nursingknowledge.

 Abilitytoinitiateorparticipateinplanning,coordinating,implemen
tingandevaluatingprogrames to meet client needsand support
nursingpractice.
 Demonstration ofadvanced judgmentand decision-
makingskills.
 Criticalanalysis ofandinfluenceon health policy.
Development of theFramework:
Oneofth
efirstprioritiesofthevicepresidentandCNO(ChiefNursingOfficer)
oftheCalgaryHealthRegionwastodevelopavisionfornursinginther
egion.Throughthedevelopmentofthisvision,itbecameapparent
thatamissionfornursingwasalsoessential. As this
workprogressed,anevident need emerged to establish a
definition of
professionalpractic
eandaguidelineorframeworkthatnursescouldutilizeonadailybasis
to achievethe vision and mission ofnursingin the region.

The Art of Nursing:
Nursesdemonstrateethical,
insightful,caringpracticeb
yfocusingonthehealthand
well-
bein
gofindividuals,familiesan
dcommunitiesishealthand
duringepisodesofillness
andtransition.
Attributes ofPractice:
Autonomousprofessionalpractice
innursingrequires takingpersonal
excellenceinpracticeandeffective
collaboratio
nwithmultidisciplinaryteammembers
edsofthepopulation.
Competence:
Nurses‘competenc
eisgroundeduponnursingt
heory,scientificknowledge
andexperience,andisreflect
edineverydaypractice.Itise
nhancedthroughcontinuou
slearning,sharedthroughm
entorshipandsupportedthr
PersonalCommitment:
Nursesdemonstrat
ecommitmenttotheprofessionbyvaluingnurses
ontributingoftheadvancementoftheprofessionand
ystrivingforexcellence in patient care.
 Theframework is congruent with the values
oftheCalgaryHealthRegion

 (Honesty,Integrity,Dignity,Trust,Respect,Responsiveness,Crea
tivity andLearning).Itreflectselementsthatarecommontoother
professionalpracticeframeworksdescribed in the literature.

 Theframeworkreinforcestheprerequisitesforthepromotionofsaf
e,competentandethicalnursingpracticethatareinherent:inthestand
ardsofpractice&theprofessionalbodythat regulates the practice
ofregistered nurses in the province.

 TheframeworklogodepictedinFigure1wasdesignedbyoneofthe
membersofRegionalNursingcouncilandisanexpressionofherbelie
fthatthenurse‘scaphastraditionallybeen an important symbol of
professionalism in nursing.
Implementationofthe Framework:

 Numeroussessionswereheldtofamiliarizenursingstaffwiththefra
mewkwhenitwas first launched.


 Introductiontotheframeworkisnowroutinelyincorporatedintothe
orientationofallnewnurses who join theRegion.
 Theframe-workalsogives the development of preceptorsand
changenurses.

 Themajorelementsoftheframeworkhavebeenlinkedtotheexpecte
dRN,LPNandRPNcompetenciesarticulatedinjobdescriptions,and
applicationoftheframeworkinpracticeisnotincorporatedintonurse
‘songoingprofessionaldevelopmentandcontinuingeducation
plans.
 Furtherelaboration offrame work will beongoing. For
exampleuse of the
frameworkha
sexposedtheNeedtoclarifysomeofitsterms;suchhas―insightfulpr
actice .
‖
EvaluationandResearch:
Nowthatth
eProfessionalPracticeFrameworkhasbeenarticulated,itwillbeimp
ortanttodeterminetheeffectivenesswithwhichitisbeingimplement
edacrossthemanysitesandsettingsinthislargeregionalhealthauthor
ityandmeasureitsimpactonpracticeandpatientoutcomes.Overthec
ourseofthenextseveralyears,specificimplementationinitiativeswi
llbetargetedforevaluationandresearch.Anoverchangingframewor
kwillbedevelopedtoguidetheevaluationofspecificinitiatives.Ans
werswillbesoughttosuchquestionsas:Whatfacilitated―internaliz
ation‖oftheProfessionalPracticeFramework?
Diditsimplementationchangenursingpracticeofselectunits?
Di
dchangesinnursingpracticeaffecttherolesofothermembersofthehe
althcareteam?
Wha
tdifference,ifany,didimplementationofaProfessionalPracticeFra
meworkmakeinjobsatisfactionandpatientoutcomes?
Whatwentwellinimplementingtheframework?What could have
been done differently?

Scope inNursing Practice:
Nursin
gisresponsibleforarticulatinganddisseminatingcleardefinitionsof
therolesnursesengagein,andtheprofession‘sscopeofpractice.Nati
onalprofessionalorganisationsbeartheresponsibilityfordefiningn
ursingandnurses‘rolesthatareconsistentwithacceptedinternational
definitionsarticulatedbytheInternationalCouncilofNurses,andrele
vanttotheirnation‘shealthcareneeds.Whilenurses,throughprofessi
onal,labourrelationsandregulatorybodies,bearprimaryresponsibil
ityfordefining,monitoringandperiodicallyevaluatingrolesandsco
peofpractice,theviewsofothers in societyshould be
soughtandconsidered in definingscopeof practice.
Th
escopeofpracticeisnotlimitedtospecifictasks,functionsorresponsi
bilities
bu
tincludesdirectcaregivingandevaluationofitsimpact,advocatingfo
rpatientsandforhealth,supervisinganddelegatingtoothers,leading,
managing,teaching,undertakingresearchanddevelopinghealthpol
icyforhealthcaresystems.Furthermore,asthescopeofpracticeisdyn
amicandresponsivetohealthneeds,developmentofknowledge,and
technologicaladvances,periodicreviewisrequiredtoensurethatitco
ntinuestobeconsistent with current health needsand supports
improvedhealth outcomes.
Nationalnurse
sassociations(NNAs)havearesponsibilitytoseeksupportforlegisla
tionwhichrecognisesthedistinctiveandautonomousnatureofnursin
gpractice,includingadefined scopeof practice.
Background:

 Thescopeofpracticeisdefinedwithinalegislativeregulatoryframe
work,andcommunicatestootherstheroles,competencies(knowled
ge,skillsandattitudes)andtheprofessional accountabilityof
thenurse.
 Nursing‘sauthoritycomesfromevidence-
basedknowledgerelatedtoitssphereofpractice.


 However,nursingisalsoalliedtootherhealthprofessionsthroughits
collaborating,referring,andco-
ordinatingactivities,an
dthushasdevelopedadistinctaswellasasharedbodyof knowledge
andpractice.

 Thepracticeandcompetenceofanindividualnursewithinthelegal
scopeofpracticeisinfluencedbyavarietyoffactorsincludingeducati
on,experience,expertiseandinterestsaswellas thecontext of
practice.

 Therefore,definitionsofrolesandscopeofpracticeneedtoreflectw
hatisdistinctlynursing,whilecommunicatingthemultidisciplinary
andinterdisciplinarynatureofhealthcare.

 Nursesrequireappropriateinitialandongoingeducationandtrainin
gaswellaslifelonglearningtopracticecompetentlywithintheirscop
eofpractice.Therefore,nursingmustensure thatnurse
educatorsandnursesmanaging
nursin
gservicesareexperiencednurseswithsuitablequalificationsandund
erstandingofthecompetenciesandconditionsrequiredtodeliverqua
litynursingcareinthecurrenthealthcareenvironment.
 To enablethe professionto provide competent
leadership,NNAs should bevigilant
i
nassuringthatnursesarepreparedwiththenecessarycompetenciesto
functioninleadershiprolesat all levels of the healthsystem.

 NNAsarealsoresponsibleforensuringthatnursesaremajorpartici
pantsintheplanning anddirectionofnursing education,nursing
services
,regulatorybodiesandotherhealthrelatedactivities.Nursingisadyna
micprofessionthathasevolvedinresponsetochangingneeds,
demands and resources of our society.

 Thecomplexityofthehealthcaredeliverysystemtodayissuchthatt
heroleandresponsibilityof thenursewithin this systemcanchange.


 Eachregisterednurseisresponsibleandaccountableformakingdec
isionsandpracticinginaccordancewithhis/
hereducationalbackgroundandexperienceinnursingwithin the
statutoryparameters ofthe NursePractice Act.
The Scope ofNursing Practice:
 Nursing,likeother professions,isaccountableforensuring
thatit
smembersactinthepublicinterestandprovidetheuniqueservicethat
hasbeendesignatedto thembysociety. This process is
calledprofessional regulation.

 Theprofessionofnursingregulatesitselfthroughdefiningpractice,
establishinganeducationalsystem,providingresearchtofurtherdev
elopthepracticebaseanddevelopingthe standardsof practice anda
code of ethics.

 Inturn,thestate,throughstatues,atteststothepublicthatregisteredn
ursesmeetminimalstandardsforpracticeandprohibitsunlicensedin
dividualsfrompracticingasregistered nurses.

 Thelegalboundariesofthescopeofpracticearedeterminedbythede
finitionofnursingfoundintheNursePracticeAct(NPA)andprovidet
hebasisforinterpretingthepractice of theindividual registered
nurse.

 Sinceeachstatehaslegalauthorityfortheregulationofnursing,thed
efinition,andtherefore the scopeof nursingpractice
mayvaryfrom stateto state.
 However, thepurpose ofthe lawremainsconsistent to protect
the public.
Nurse Practice Act:

 TheNursePracticeActwasenactedbythelegislaturetoregulatethe
practiceofnursingandtodefinetheparametersofnursingpracticefor
thepurposeofprotectingthepublic.

 Theactdoesnotaddressspecificnursingdutiesthatarepropertobep
erformedbynurses, or hospital staffingpatterns, labor practices

or employmentcriteria.

 TheNursePracticeActisdesignedtoprotectthepublicfromincomp
etentnursingpractice, not to protect nurses
fromdiscriminatoryorquestionable employmentpractices.

 Eachnurseisresponsibleandaccountableformakingdecisionsand
practicinginaccordance with
thatindividual'seducationalbackgroundandexperience innursing.
Nursing
Practice
inDifferent
Settings
:Individual
RNs
Responsibilit
y:

 Theregisterednurseisresponsibleandaccountable,professionally
andlegally,fordetermininghis/herprofessional scopeof nursing
practice.

 Sincetheroleandresponsibilitiesofnurses,andconsequentlythesc
opeofnursingpractice,iseverchangingandincreasingincomplexity
,itisimportantthatthenursemakesdecisions regardinghis/herown
scopeof practice.
TheNurseManager &NurseExecutive's
Responsibility:

 Asaregisterednurse,thenursemanagerisresponsibleandaccounta
ble,professionallyandlegally,for determininghis/herprofessional
scopeof practice.


 Thenursemangermakesdecisionsregardingtherolesandresponsi
bilitiesfornurseswithin the institution or agencyin order to
providequalitycare.

 Thenurseexecutive,inachangingandcomplexhealthdeliverysyst
em,isknowledgeableregardingchangesinrulesandregulations,accr
editationstandardsandstandardsofcareandpractice,inadditiontoev
aluationoftheboundariesspecifiedintheNurse Practice Act.
 Thenurseexecutiveand/
orthenursemanagerfacilitatechangestoassurequalitypatientcare
outcomes and developmechanisms that will promotethe same.
Mobile Nursing Practic:

I
n1984aneedwasseentooffermoreextensivehomehealthcareforloc
alresidentswho preferred to receiveneededcare in their
ownhomes.

Thi
senabledmanytoreducecostsandremainintheirhomes,atleastforal
ongerperiod oftime.

 ThisorganizationbecameknownasMobileHealthCare,Ltd.andw
aslaterchangedtoMobileNursingServices,Ltd.Thiswastheareas‘fi
rstprivatehomehealthcaredeliverysystem.
 Itwasthefirsttooffersuchservicesatalltimesofthe day
andnight
.Previouslysuchcarewasavailableonlyduringregularbusiness
hours.

 MobileNursingServiceshasbeenaleaderandinnovatorinthefieldo
fhomehealthcareandhastransformedthisimportantmethodofhealt
hcaredeliveryinthesoutheastIowaarea.

 Itisthelargestandoldesthomehealthcaresysteminthearea,exceptf
orpublicorganizations,andithashadafavorablecompetitiveeffecto

nthose,resultinginoverallimprovedcare for thearea
residentsfromavarietyof public andprivate sources.

Mobil
eintroducedmanyinnovationsintothelocalhomehealthcaremarket
andcontinues to do so.
Mobile nursing services:
Thes
eservicesprovidehometeachingandcareforpatientswithvariedn
eedsandhealthproblems.
 Patientsdischarged earlyfrom hospitals.
 Patientssufferingfromchronicand acute medical problems.
 Surgical Patients.
 PatientsrequiringIVtherapy.
 Theelderly.
 Respiratorypatients.
 Theseriouslyill.
 Patients in need of medicationmanagement (includingpain
control).
 HospiceConcept.
 Ventilator Dependent.
 (Assistance)with Bathing,Dressing,Meals,
Transportation,LightHousekeeping.

Service
smaybecoveredbyMedicare,Medicaid,privateinsurance,privatep
ayment,VAor other third partypayers.
Milit
arN
ursi
ng
Serv

ices:
First
Wor
ldW
ar:
TheMilitaryNursin
gServicehasitsoriginfromtheArmyNursingServiceformedin1881
partofRoyalArmy.TheArmynursesservedinFlanders,theMediterr
anean,theBalkans,theMiddleEastandonboardhospitalships.After,
thewaron1stOctober1926,theNursingServiceswasgrantedperman
entstatusinIndianArmy.Thisdateisformallyrecognisedastheform
ationdayofMilitaryNursingService,thoughinactualitsoriginsoccu
rred 45 fiveyearsbefore.
SecondWorld War:

 Withtheoutbreakofsecondworldwar,nursesonceagainfoundthe
mselvesservingallover theworld.

 Duringthemiddleofthewarin1943,theIndianarmoftheNursingSe
rviceswasseparatedthroughIndianMilitaryNursingServiceOrdina
nce,1943andredesignatedit,there
byconstitutingtheMilitaryNursingService(MNS) in its present
form.
 The OfficersoftheMilitaryNursing
ServicearegovernedbyIndianMilitaryNursingService Ordinance
1943and MilitaryNursingServiceRules, 1944.

 TheSection5oftheordinanceprovidesthat,allmembersoftheIndia
nMilitaryNursingServiceshallbeofcommissionedrankandshallbe
appointedasofficersoftheIndianMilitaryNursing Service
bytheCentralGovernmentbynotificationintheOfficialGazette.

 TheNursingServiceOfficersarealsosubjecttoArmyAct1950,Ar
myRules1954,DefenceServiceRegulationsandvariousGovernme
ntOrders,ArmyInstructions,ArmyOrders, issued from time to
time.


 TheMilitaryNursingServicestandsoutasoneoftheoldestservices
wherewomenhavecontributeddirectlytothenation‘swareffortbypr
ovidingcaretothesickandwoundedsoldiers. This is also trueforall
the armedforcesof theworld.

 ThearmynurseshavemadeapermanentplaceineveryNation‘shear
tbynursing
millions of sickandwoundedsoldiersback to health.
 The OfficersofMilitary
NursingServicehaddistinguishe
dthemselvesintheSecondWorldWar,throughthecareofthesickand
woundedsoldiersinIndiaandalsoatmanyforeigntheatres of war.

 Postindependence,theNursingOfficerscaredforthewoundedsold
iersinfivemajorbloodyconflicts with the neighboring countries.
RankStructure:
The various ranks of theMilitary Nursing Serviceare listedbelow
in descending order:-
 Commissioned Officers.
 Major-General.
 Brigadier.
 Colonel.
 Lieutenant-Colonel.
 Major.
 Captain.
 Lieutenant.
Presentlyther
earenopersonnelbelowofficerrank(PBOR)inMilitaryNursingSer
viceastheothernursingpersonnelsuchasNursingAssistants,Ambul
anceassistant;StretcherBeareretc arepart ofArmyMedicalCorps.
Tele- nursing:


 ReferstotheuseofTelecommunicationsandinformationtechnolo
gyforprovidingnursingservicesinhealthcarewheneveralargephysi
caldistanceexistsbetweenpatientandnurse, or between
anynumbersofnurses.
 AsafielditispartofTele-health,andhasmanypointsof
contactswithother medicalandnon-
medicalapplications,suchasTele-diagnosis,Tele-
consultation,Tele-monitoring,etc.
 Tele-
nursin
gisachievingalargerateofgrowthinmanycountries,duetoseveralfa
ctors:thepreoccupationindrivingdownthecostsofhealthcare,aninc
reaseinthenumberofagingandchronicallyillpopulation,andtheinc
reaseincoverageofhealthcareto distant, rural, small or
sparselypopulated regions.
 Amongitsmanybenefits,Tele-nursingmayhelpsolveincreasing
shortage
sofnurses;toreducedistancesandsavetraveltime,andtokeeppatient
soutofhospital.Agreaterdegree of job satisfactionhas been
registeredamong. Tele-nurses.
Applications:
 OneofthemostdistinctiveTele-
nursingapplicationsi
shomecare.,Innormalhomehealthcare,onenurseisabletovisitupto
5-7patientsperday.UsingTele-nursing,onenursecan―visit 12
‖ -
16patientsinthesameamountoftime.[Needssource]
 AcommonapplicationofTele-nursingisalsoused
b
ycallcentersoperatedbymanagedcareorganizations,whicharestaff
edbyregisterednurseswhoactascasemanagersorperformpatienttri
age,informationandcounselingasameansofregulatingpatientacce
ss and flowand decrease the useof emergencyrooms.
 Tele-
nursin
gcanalsoinvolveotheractivitiessuchaspatienteducation,nursingT
ele-
consultations,examinatio

nofresultsofmedicaltestsandexams,andassistancetophysicians in
the implementation of medical treatmentprotocols.
TheNursing Robot:

 "DevelopmentofaNursingRobotSystem"includedthedevelopme
ntofamobilerobot system (theNursing Robot) to help
physicallyhandicapped people.

 Completedin1986,theNursingRobotwasoneofthefirstfullyfunct
ioningmobilerobotsequippedwithamanipulatorarm.Alsointegrat
edweresevendifferentsensorsystems.

 ThesystemwascontrolledbyfournetworkedonboardSinclairSpec
trumComputersandanoff-boardIBM-PC.

 ThisdocumentdescribesthefeaturesofthemobileNursingRobotS
ystemdevelopedat the Technion.

 TheNursingRobotSystemcomprisesthreemajorcomponents:asel
f-
propelledvehicle
,aroboticarmmountedonit,andacommunicationspost(workstation
)nexttothe disabledperson'sbed.
 Onboardthemobilerobotlow-
cos
tmicrocomputersareinterconnectedasahierarchicalnetwork,inord
ertocontrolavarietyofactivities:Sensordataprocessing,motion
control,path-planning,communication, and others.
 Thevehiclecan moveautonomouslyin a room with
unexpectedobstacles.
Nursing in
Occupationa
l
Health
:Occupation

alHealthNur
ses(OHN):
Areregistere
dnurseswhoindependentlyobserveandassesstheworker'shealthsta
tuswithrespecttojobtasksandhazards?
Usin
gtheirspecializedexperienceandeducation,theseregisterednursesr
ecognizeandpreventhealtheffectsfromhazardousexposuresandtre
at workers'injuries/illnesses.
Scope:
Educationallyprepare
dtorecognizeadversehealtheffectsofoccupationalexposureandad
dressmethodsforhazardabatementandcontrol,OHNsbringtheirnu
rsingexpertisetoallindustriessuchasmeatpacking,manufacturing,
constructionaswellasthehealthcareindustry.OHNs:

 Havespecialknowledgeofworkplacehazardsandtherelationshipt
otheemployeehealthstatus.

 Understandindustrialhygieneprinciplesofengineeringcontrols,a
dministrativecontrols, and personalprotective equipment.

 Haveknowledgeoftoxicologyandepidemiologyasrelatedtothee
mployeeandthework site.
OHN Activities:
 Observationandassessment ofboth the worker and the work
environment.

 Interpretationandevaluationoftheworker'smedicalandoccupatio
nalhistory,subjectivecomplaints,andphysicalexamination,along
withanylaboratoryvaluesorotherdiagnosticscreeningtests,industr
ialhygieneandpersonalexposuremonitoringvalues.
 Interpretation of medicaldiagnosis to workers andtheir
employers.

 Appraisal of thework environment for potential exposures.
 Identification ofabnormalities.
 Description of theworker'sresponse to theexposures.
 Management ofoccupational and non-occupational illness
and injury
 Documentation oftheinjuryor illness.
AcademicPreparation:
OHNswithvaryingdegrees of academic preparation from
entrylevel to PhD work incapacitiescommensuratewith
theirexperienceand academic preparation:clinicalnurse,clinical
nurse manager, nurse manager,corporatenurse, nurse researcher,
nurse educatorandnurse consultant
School health nurses:
Schoolnurse
sareprimarycarenursesforschoolchildren.Theyworkwithindividu
alchildren,youngpeopleandfamilies,schoolsandcommunitiestoim
provehealthandtackleinequality.Inadditiontheyarerecognizedasc
ontributingtoraisingeducationstandards.
A
schoolnurseisaqualified,experiencedprofessionalandtheonlytrain
ednurseworkingacrosshealthandeducationboundaries.Theyalsop
rovidethelinkbetweenschool, home and the community.
School health nursesresponsibility
Schoolnurseshave special responsibilityfor:-
 Promotinghealthylifestyles and schools.
 Child andadolescent mental health.
 Chronicandcomplexhealthcareneeds inchildren
andyoungpeople.
 Vulnerablechildrenandyoungpeople.
Activities ofschool health nurses:
The schoolnurses work includes:-
 Healthassessments for childrenatentrance toschool when

required.
 Individual health interviewsoffered toyoungpeople aged 13-
14years.
 Immunisationprogrammes.
 Child protection.
 Healtheducation.
Space Nursing Society(SNS):

 Isaninternationalspaceadvocacyorganizationdevotedtospacenu
rsingandthecontributiontospaceexplorationbyRegisteredNurses.
SNSisanaffiliated,non-profit specialinterestgroupassociated
with theNationalSpace Society.

 TheSNSprovidesaforumforthediscussionandexplorationofissu
esrelatedtonursinginspaceanditsimpactupontheunderstandingof
earthboundnursingthroughconference participationand its
newsletterExpanding Horizons.

 Theinformationbeinglearnedinthemicrogravityenvironmentofs
pacehastremendousapplicationsforthe bed-bound patienton
earth.

 Bedrestisconsideredanalogoustosomeofthereactionstheastrona
utshaveexperiencedinspace,whichincludeinnerearfluidshifts,los
sofplasmavolume,muscleatrophy,demineralizationandcalcium/
bone loss.

 Ifoneweretoconsidertheissuesofconfinedspaces,closedecologic
alsystemswithlittlepersonalspace,andpsychological-
socialinteractions,therearemanyearth-boundcounterparts that
couldbenefitfrom what is being learned viaspaceresearch.
LegalRegulation:
Nursin
gpracticeinConnectiutisregulatedbyConnecticutstatutes.Thepro
fessionalnurseisresponsibleandaccountableformakingdecisionst
hatarebasedupontheindividual'seducationalpreparationandexper
ience in nursing.

Behaviorsandactivitie
softhenurserelatingtothescopeofpracticethatcouldleadtodiscipli
naryaction are:-

 Performingactsbeyondtheauthorizedscopeofpracticefortheleve
lofnursingforwhich the individual is licensed.

 Assumingdutiesandresponsibilitieswithinthescopeofnursingpr
acticewithoutadequatepreparation orwhen competencyhas not
beenmaintained.

 Failingtotakeappropriateactionortofollowpoliciesandprocedur
esinthepracticesituationdesigned to safeguard thepatient.

 Assigningordelegatingunqualifiedpersonstoperformfunctionso
flicensednursescontraryto theNursePractice Act or to
thedetriment of patientsafety.

 Willfullyornegligentlyfailingtotakeappropriateactioninsafegua
rdingapatientorthe public fromincompetentpracticeperformed
byaregisteredprofessional nurseor a
licensedpracticalnurse. "Appropriateaction"
mayincludereportingtotheStateBoardofExaminersfor
Nursing(SBEN).

 ConnecticutStateBoardofExaminersforNursing(SBEN)TheSB
ENwasestablishedin1905bythestategovernmenttoprotectthepubl
ic'shealthandsafetybyoverseeingcertainaspectsofthepracticeofn
ursingoflicensedpracticalnurses,registered nurses andadvanced
practice registerednurses, but not certified nurse aides.

 TheSBENachievesthismissionpursuanttoConnecticutGeneralS
tatutesSection20-88and20-
9
0byadvisingthecommissionerofpublichealthaboutregulationsfor
nursingprogramsandapprovingprogramswithinschoolsofnursing
andbyadjudicatingcomplaintsfiledagainstlicensed
practitionersandimposingsanctionswhenappropriate.

 TheSBENtakesactionagainstthelicensesofthosenurseswhohave

exhibitedunsafenursingpractice.Inaddition,theSBENreviewsand
providesadvisoryguidanceregardingscopeofpracticequestionsusi
ngthe"NursingCompetency/ScopeofPracticeDecision--
MakingModel.

 TheSBENhastheauthoritytosuspendorrevokealicenseordiscipli
neanurseformisconduct,incompetenceornegligence.Theburdeni
suponthenurse,thelicensee,toactatalltimesasareasonableandprud
entprofessionalshouldact,inaccordancewiththe prevalent
professional standards.

 TheSBENcangivedirectionbeforeagivenactisperformedaboutw
hetheritispermissibletoperformthatparticularact.However,thisdi
rectionmustbespecificallyrequested.

 AroutinefunctionoftheSBENistorespondtoorcommentuponpra
cticequestions.Themajorityofsuchrequestsareforclarificationofa
givenactivitywithregardtothenurse's "proper"scopeofpractice.
 In specific instances specific guidance isgiven inaposition
statement.
 It is not areasonableexpectationthat tSBEN canrespond
toeachandeverynurse'sspecificpractice questions with position
statements.

 Nursesneedtorecognizethat,becausetheyareindividuallylicense
d,theyareliablefornursingjudgment and ctionandobligated
tomakeresponsiblepractice decisions.

 TheSBENisauthorizedbythestatetodisciplinenurseswhoareuna
bleorunwillingtopracticecompetently,butithasnoauthorityoverh
ealthfacilitiesorotherhealthcareproviders.
Tends InNursingPrtice:
Trend
sinnursingarecloselytiedtowhatishappeningtohealthcareingener
al.Trendsarefascinatingphenomena,buttheydonotexistinvacuum
s.Mostareinterrelated;onetrendoften spawns
another.Althoughtrendsare morethan fads, theyarefar from
money-

backguarantees
.Wewatchtoanticipatethedirectionthataparticulartrendwilltakeus
,toremovetheelementofsurprise.Whenwelookbackontrends,how
ever,somewillhaveheraldedpermanentchanges,butothersmighth
avebeennomorethanblipsontheradarscreen.
Broadening Focus:

 Thefocusofnursinghasbroadenedfromthecareoftheillpersontoth
ecareofthepeopleinillnessandfromcareofonlythepatienttocareoft
heclient,thefamily,andinsome instance the community.
 In the past, nursing, likemedicinewas orientedtowards
disease and illness.

 Today,thereisincreasingrecognitionofpeoplesneedforhealthcare
asdistinctfrom
illness careandof thenurses‘ independent functions in this area.

 Anotheraspectofthebroadernursingfocustothemovementofnursi
ngpracticeintothecommunity.Inasense,thereisareturntothebeginn
ingofnursing,thatisbeforeitbecomes a recognizedoccupation.

 Throughoutmuchofthiscenturyhowevernursesworkedonlyinins
titution,increasinglynursingservices are provided in
communityoften in homes and clinics.

 Thenursingactivitynotonlyassiststhosewhoareillbutalsohelpsth
osewhoarehealthyto maintain orcontinuetheir health.
Scientific basis:
I
nthepastnursinglargelywaseitherintuitiveorreliedonexperienceor
observationratherthanonresearch.Throughtrailanderrortheindivi
dualnursesdiscoveredwithmeasureswouldassisttheclientandman
ynursesbecamehighlyskilledinproviding carethroughexperience.
Technology:
Technolog

yormechanizationisbeingappliedinthehealthfieldextensively.Cer
tainareasofahospitalaremoretechnologicthanothers.Nursesfindth
emselvesinthemidstofthisrapidlychanging,increasinglytechnolo
gicenvironmentinhospitalandinclient‘shomes.
Indicators of increasingtechnology include:-
a. Th
eproliferationoftechnologicequipmentusedincaseofclientsinhosp
italsandhomes.
b. Theincreasinghome andself care equipment.
c. Useof computers in manyareasofhealth care.
Manynurse
sfeeltheyedmoreeducationtoobtaintheknowledgeandskillsnecess
arytousethenewtechnology.Hightechnologyhasenablednursesto
gatherclientassessmentdatathroughnon-
invasivetechniques(E.g.pulseoxymetry)ratherthan,through
thecostlyinvasive procedure.
Renewedfocusingcaring:
Theincreasinguseoftechnologyinhospitalsandhome
shascreatedanincreasingneedtohumanize.Nursinghastraditionall
ybeenacaringandhumanizingprofession.Indicators of this
trendinclude:-
a. Th
eincreasingnumberofprofessionals,articlesandbooksaboutbalanc
ingofcaringandtechnical skills.
b. Manystudies regardingcaring as anaspect of nursing.
c. Increasingrecognition in nursingof needs ofclients in
technologyandenvironment.
Nurse
sarebecomingmoreinvolvedinhealthcarereform.Nursing‘sAgend
afor
Healt
hCareReformSupportsthecreationofhealthcaresystemthatensure
daccess,qualityandservicesataffordablecosts.Theplanforreformf
ocusesonprimaryhealthcareserviceandpromotions, restorations
andmaintenance of health.
Healthypeople2010arethedocumentfor publichealthpolicyfor

thene
wmillennium.Itoutlinesgoalsforvulnerablepopulationssuchaslo
wincomegroups,minorities,personswith disabilities.
Politicalactivismandcommitmentar
eapartofprofessionalism;howeverpoliticsareanimportantaspectof
thedeliveryofhealthcare.Thereforethenursesshouldviewpoliticsa
sareality
tha
tincludestheartsofinfluence,compromiseandsocialinteractions.N
urseshavebeeninvolvedinadifferentsortofpoliticsinschoolsofnurs
ingandinhealthcaresetting.Whenseekingmoreadditionalresource,
moreselfdirectionsacountabilitywithauthority.Theskillsgainedin
suchexperiencescanbetransferredtothepoliticofhealthcarepolicy
making.
Aslon
gasnursesmaintainedinvolvementinhealthcarepolicyandpractice,
outsiderscan‘tattempttoimposetheirwillonnursingandnursingpra
ctice.Nursingshouldhaveitsownvoiceindecisionmadeintheseand
numerousotherareasaffectingthepracticeandqualityofnursingcar
e.Allthoughnurseshaveoftensuccessfullypreventedinfringement
on theprofessions selfgovernance, the future of nursing requires
that
nursesindividuall
yandcollectivelyseekagreaterinfluenceonhealthcarepoliciesaffec
tingnursingpractice.
Changing trends in nursing:

 Nursinghasoriginatedfromtheword‗nurturing‘,whichmeansnour
ishing,helpingingrowthanddevelopmentofahumanbeing.Inthepa
st,nursingwasfamily-basedwork.

 Modernnursingbeganinthe19thcenturyundertheleadershipofFlor
enceNightingale.

 Theaimofnursingwasonlytopromotetherecoveryofpatients.Evenn
ow,the
centralconcernofnursingis‗nurturingthehumanbeings‘.

 Thepresentdaynurseprovidescareforthepeopleinhealthandillnes

s.Nursingisoneofthehealthservices,whichcontributestowell-
bein
gofanindividual,familyandcommunity.Therefore,nursingisdefin
edasahumanisticsciencededicatedtomaintainandpromotehealth,p
reventing
illness,careforandrehabilitationofthesickanddisabledpersons.

 Nursingprocessincludesdoing,thinkingandinteractioncomponen
t.Itismainlyandbasicallyaproblem-
solvin
gapproachofnursingcares.Thenursingprocessconsistsoffoursteps
-
Assessment
,Planning,ImplementationandEvaluation.Eachstepofanursingpro
cessleads to thenext one, whichmakes it acontinuingcyclic
process.
ModernTrends innursingpractice:
Thepublicperceptiono
falternative,complimentarytreatmentmethodshasbeenchangingo
verthepastfewdecades. Inthelate1960‘sandearly1970‘s
―
Natural‖―NewAge ,
‖ ―SelfHelpMovements‖begintoattractfollo
wers,firstamongconsumersandlateramonghealthcarepractitioner
s.Duringthattimeprovide,therewasagrowingtrendtowardsrejectio
noftraditionalmedicinebecauseofit‘sperceiveinvasiveness,painfu
lness, cost andineffectiveness. Arekindledinterest in
Easternreligions,lifestyle
andmedicin
ehasflueledthedevelopmentofcontemporaryholistic,alternative/
complementarymodalities
.Clientsareseekingoutalternative/complementarytherapiesbecaus
emostsuchtherapiesarenon-
invasive,holisticandinmanyinstanceslessexpansive thengoingto
aphysician.
I
n1993alandmarksurveyfoundthat1/3oftheUSpopulationhadused
somenon-
traditionalalternativ
emethodsoftreatmentsinadditiontothestandardmedicaltreatment.

In1992theUSGovernmentestablishedanOfficeofAlternativeMedi
cines(OAM)attheNationalInstituteofHealth.―Oneofthereasonsf
ortheOAM‘screationwastheFederalGovernmentsrecognitionthat
UScitizensarepersuingalternativemethodsofhealthcarewithunpre
dictedenthusiasm .
‖
In1992,theOAMwasallocated2milliontoinvestigatetheuseofnon-
traditionaltreatmentmethods.Congressincreased
theOAMsbudget to 20 million fortheyear1998.A fewtherapies
investigated bythe OAM-1995 include:
 Biofeedback tocontrol pain.
 Acupuncturetorelieve depression.
 Imageryto controlasthma.
 Ayurvedic medicineto treat Parkinson‘s disease.
 Musictherapyto treat brain injuredclients and
 Sharkcartilage to treatcancer.
Roleofprofessionalnurse:
Thefollowingnurserole
sarewaysofdescribingthenurse‘sactivitiesinpractice.Eachrollisde
scribedasaseparateentityforthestateofclarity.Howevertherollisno
tinactualityexclusiveof one another.Inpractices,several roll
oftencoincide.
1.) Care provider:

 Thegoalofnurseinthisrollistoconveyunderstandingaboutwhatisi
mportantandto provide care.

 Thenursesupportstheclientbyttitudeandactionsthatshowconcern
fortheclientwelfare andacceptance of theclient as aperson, not
merelya mechanical being

 Caringiscentraltomostnursinginterventionandanessentialattribut
eoftheexpertnurse.
2.) Communicator/helper:
 Communicationsshapes
therelationshipsbetweennursesandclients,nursesandsupport

persons,and nurses and colleagues.
 Communicationsfacilitatesall nursing actions.

 Thenursecommunicatestootherhealthcarepersonnelthenursingin
terventionsplannedand implemented foreachclient.
 Nursescommunicatespertinentinformationverbally-at-
changeofshiftreports,whenclientsareshiftedtoanother
unit,atclientsrounds,andwhenclientsaredischargedto
anotherhealth care agency.
3.) Teacher:

Itisaninteractiveprocessbetweenateacherandoneormorelearnersi
nwhichspecificlearningobjectivesordesiredbehaviorchangesarea
chieved.thefocusofthebehaviorchange is acquiringanew
knowledge ortechnical skills.
4.) Counselor:

 Itistheprocessofhelpingtheclienttorecognizeandcopewithstressf
ulpsychologicorsocialproblems,
todevelopimprovedinterpersonalrelationships,andto
promotepersonalgrowth.
 It involves providingemotional, intellectual andpsychologic
support.

 Thenursefocusesonhelpingthepersondevelopnewattitudes,feelin
gsandbehaviorsratherthen onpromotingintellectualgrowth

 Thenurseencouragestheclienttolookatalternativebehaviors,reco
gnizethechoices, anddevelop a sense ofcontrol.
5.)Client Advocate:

 Advocacyinvolvesconcernforanddefinedactionsinbehalfanother
personororganizingto bringabouta change.
A―clientadvocate‖isanadvocateofclient‘right.

 Itinvolvespromotingwhatisbestfortheclient,ensuringthattheclien
t‘needsaremet, andprotectingthe client‘s right.
6.)Change agent:


 Isapersonorgroupwhoinitiateschangesorwhoassistsothersinmaki
ngmodifications in them selves orin the system.
7.) Leader:
Nursin
gleadershipisdefinedasamutualprocessofinterpersonalinfluencet
hroughnursehelpsclientmakedecisioninestablishingandachievin
ggoalstoimprovetheclients‘wellbeing.
 To improve the health status and potentialofindividuals or
families

 Increasingtheeffectivenessandlevelofsatisfactionamongtheprofe
ssionalcolleagues providingcare.
8.) Manager:

 Managementisplanning,givingdirection,developingstaff,monito
ringoperations,givingrewards fairlyandrepresentingboth
staffmembersandadministrations as needed.
 Thenursemanagesthenursingcareofindividuals,
groups,families, andcommunities.

 Themanagerdelegatesnursingactivitiestoancillaryworkersandot
hernursesandsupervisesandevaluatestheir performance.
9.) Researcher:

 Nursewhowillengageinresearch,thereisagrowingexpectationthata
llnurseswillbeabletocriticallyappraiseresearchreportsandwillutiliz
eofscientificstudiesasabasisfor makingdecisions in their work.
10.) Expandednursingroles:
A
nexpandedroleisonethatanurseassumesbyvirtueofeducationande
xperience.Thenursewhoassumesanexpandedrolehasincreasedres
ponsibilityand,usuallygreaterautonomy.Nurses are
assumingexpandedroles inboth hospitals and
communitysettings.11.)Nurse Generalist:
TheANAconducts nursegeneralistscertificationprograms
tha
tissuecertificatesinelevenareas:Generalnursingpractice,medicals
urgicalnursing,gerontologicnursing,pediatricnursing,perenatalnu
rsing,collegehealthnursing,schoolnursing,communityhealthnurs

ing,psychiatric&mentalhealthnursing,nursingcontinuingeducati
on&stall Development&home Health Nursing.
12.)NurseClinician:
TheClinician‘sProvidebedsideordirectCareinaspeciality
area.Theymayormaynot
have advancededucationalpreparation.
13.)NursePractitioner:

 Theroleofnursepractitionerisanextensionofthenursesbasiccaregi
vingrole.itpreparesnursesforanexpanded rolein theprovision of
primarycare.
 Thenursepractitionermaybegeneralists.
(Eg:Familynursepractitioners)orspecialists.( eg: GeriatricNurse
Practitioners )

 Nursepractitionerinacommunityemployedinhealthmaintenanceo
rganizations,healthcenters,schools&PhysiciansOffice.

 Theyareusuallyskilledatmakingnursingassessment,performingp
hysicalassessments,counseling,teaching&Treatingminor,selflim
itingillnesses,longtermillnesses .

 Thenursepractitionersinhospitalsareoftenemployedinspecialitya
reas.eg:geriatric nursing.
14.)NurseSpecialist:
 Thenursespecialist hasadvanced knowledge&skillIn
aparticulararea ofnursing

 Thisnursespracticeinhospitalsorcommunities.Inhospitalssuchnu
rsesgivedirectclientcare, adviceother nurses&co-ordinate
nursing givenbyothers.

 Theclinicalnursespecialistsarearolemodel&areexpectedtokeepa
breastofnewdevelopments in the field.
Summary and conclusion:
Eachnursemustdeterminehis/
he

rownindividualscopeofpractice.Todetermineone'sscopeofpractic
e,thenursemustunderstandtheNursePracticeActandassesshis/
herow
nevolvingsetofcompetencies.Anurse'sscopeofpracticewillchange
overtime,withadditionalexperienceandeducation.Determiningsc
opeofpracticeisanobligationandresponsibilityjointlysharedbyindi
vidualnurses,nursemanagers,nurseexecutivesandeducators,aswel
lastheregulatoryagenciesandprofessionalorganizations.Thisarticl
eisintendedtoprovidenurseswithinformationandtoolstoassistthem
indeterminingtheirscopeofpractice.TheprocessofdevelopingaPro
fessionalPracticeFrameworkfortheCalgaryHealthRegiondemand
edconsiderabletimeandeffortonthepartofamultitudeofnurses.Ther
esolvetoreflectaccuratelythelanguageofnursesindevelopingthefra
meworkwasvitaltodefiningprofessionalpracticeinamannerthanpr
omotedownershipofthefinalproductbynursesintheRegion.Itwilln
owbeimportanttoexaminetheextenttowhichelaborationofthisfram
eworkhelpsnursesachieveincreasedmeaningandcontinuallystring
toattainhigherlevelsofexcellenceintheirwork.Itishopedthatthedev
elopmentofanexplicitmodeltoguidepracticewillultimatehelpnurse
sfeel prideixtheir professionandvalue thetremendous
contribution.
BIBLIOGRAPHY:
1. Potte
r&Perry,FundamentalsofNursing,5
th
Edition,MosbysPublications
,Pageno22.
2. Patrici
aA.Potter,FundamentalsofNursing,3rdEditionMosbysPublicatio
n,Pageno 29– 3.
3. Lois White, Fundamentals Of Nursing,Mosbys Publication,
Page no: 85,224.
4. Kozier, FundamentalsOfNursing, 5
th
Edition , Page no :18~
21 , 40 , 41,
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