Diffusion and Adoption of the ANA Nursing Scope and Standards of Practice Document: Part 2 Qualitative Findings of the National Survey

Little is known about the diffusion and implementation of the American Nurses Association (ANA) Nursing Scope and Standards of Practice (NSSP) document in actual nursing practice. A subset of committee members from the ANA Committee on Nursing Practice Standards sought to answer these questions through a national survey conducted to investigate the adoption of this professional resource and accompanying competencies.

According to Matthews (2012), professional nursing organizations are expected to advocate for all nurses and the nursing profession thereby improving the voice and societal accountability of professional nurses. An example of how ANA fulfills its duty for advocacy is through this research study, gathering perspectives of nurses to better understand the barriers, strategies, and outcomes with the implementation of the NSSP. The research findings can inform ANA how to reach more nurses through the NSSP. Findings can also provide guidance to ANA members and other professional organizations about how to be aware of barriers, implement strategies, and anticipate outcomes for measures of success.

A review of literature supported the need for this study. Boolean search terms included “ANA Nursing Scope and Standards,” “nursing standards,” “standards of practice,” “nursing practice standards,” dissemination,” “adoption,” and “integration.” Most literature focused on the incorporation of specific standards or components of ANA foundational documents, and not the entirety of the scope and standards nor evaluation of successful integration or logistics of implementation. For example, Marion et al. (2017) highlighted the impact of one particular professional performance standard, Standard 8 Culturally Congruent Practice, and its application in various healthcare environments. Three articles focused on specialty NSSP documents. Sipes et al. (2017) recommended a framework for health information technology competencies, utilizing the 2015 ANA Nursing Informatics: Scope and Standards of Practice, Second Edition (NISSP). Similarly, Herena et al. (2018) used the Clinical Research Nursing: Scope and Standards of Practice as a foundation for a nurse orientation course. Gomez et al. (2017) provided examples of integrating the Nephrology Nursing: Scope and Standards of Practice into clinical practice. Gomez et al. (2022) outlined how the Nephrology Nursing: Scope and Standards of Practice can be utilized in everyday practice as a basis for quality improvement, evaluation of nursing service delivery systems, and certification activities.

Without comprehensive literature that addresses the dissemination and implementation of the NSSP document, this mixed method research was undertaken to generate new knowledge on this subject. The ANA Committee on Nursing Practice Standards national survey explored the dissemination and adoption of the NSSP document by practicing registered nurses (RNs) in the United States within Rogers’ Diffusion of Innovations Theoretical Framework (Rogers, 2003). This survey approach was used to gather researcher-developed questionnaire information. The first article (Sitzer et al., 2023) reported the quantitative aspects of the research, while this current article describes the study aim to characterize barriers, strategies, outcomes, and general comments by presenting the analysis and findings of the narrative based, open-ended questions included in the survey.

Methods

Research Design
After approval from an institutional review board (IRB), we implemented a descriptive, cross-sectional, mixed methods survey approach. We recruited a convenience sample by distributing our survey over the period of one month in 2016 via a web-based application. Informed consent was integrated into the survey platform and those who wish to participate could proceed with their voluntary responses. Researchers applied descriptive and conventional content analysis (Hsieh & Shannon, 2005) Author: This citation is not in references to describe quantitative and qualitative findings, respectively.

Researcher Description
All researchers were members of the ANA Committee on Nursing Practice Standards, a long-standing volunteer committee reporting to the ANA Board of Directors. Committee members serve a four-year term after a rigorous selection process drawn from a pool of interested ANA members. The composition of the committee represents solid content expertise from a culturally diverse group of individuals with varied educational and experiential backgrounds that include clinical nurses from different geographical settings.

The committee was charged to provide strategic planning and oversight of the development of scope of practice statements and standards of nursing practice. As part of this charge, committee members often have rich discussions about the dissemination and adoption of the NSSP and other scope and standards documents. Lingering concerns about dissemination of guiding documents into actual scope of practice prompted six committee members to volunteer to investigate these questions.

Researchers for this study had various levels of prior exposure to successful implementation of the NSSP document in their respective practice settings. Specifically, these diverse nursing and healthcare experiences were characterized as follows: two members who focused on national and state policy and government oversight of nursing practices and education; two members who worked in practice with population health/nursing populations in acute healthcare settings at a system- and hospital-level approach; and two members who provided direct patient care (one inpatient and another in a community setting) while also serving as nursing faculty in academia.

Recruitment Procedures
The target participant population was limited to practicing registered nurses in the United States who reported having awareness of the NSSP document (inclusion criteria). These nurses voluntarily completed the online survey disseminated through various professional contacts. The survey was not limited to ANA members. A total of 1,679 participants completed the survey questions.

Participants and researchers had no personal communication or interaction; content analysis of open-ended question responses was limited to examination of participants’ submitted comments to the online survey questions. Researchers were blinded to participant identity as the survey did not request any personally identifiable information.

Data Collection
The qualitative component of the 31-item questionnaire/survey had four open-ended questions related to implementation or adoption of the NSSP document, as follows:

• What are barriers to adopting and/or implementing ANA’s Nursing Scope and Standards of Practice?
• What are strategies to adopting and/or implementing ANA’s Nursing Scope and Standards of Practice?
• What are measurable outcomes from adopting and/or implementing ANA's Nursing Scope and Standards of Practice?
• Comments about this survey and/or the ANA Nursing Scope and Standards of Practice.

Within the survey platform, there were no character or word limits applied to the response fields. Answering these questions was optional; participants had the choice to answer all or none.

Data Analysis
For each of the four questions, each researcher read all responses and developed recommendations for themes and subthemes. Following this, all six researchers met to gain consensus on the themes and subthemes that would form the schemata for the coding. The six researchers then formed three dyads to complete the content analysis. Each researcher reviewed a subset of responses (e.g., in groups of 50-200 survey participants’ responses at a time) using the coding schemata. This was followed by iterative dyad meetings to further analyze and discuss coding assignments to reach consensus. The three dyads then met to analyze, discuss, and reach final consensus to determine the final coding. In the rare instance that a new theme emerged during this process, the group would reach consensus to add or delete subthemes and modify the coding schemata. This data analysis strategy facilitated the trustworthiness criteria of credibility and confirmability (ADD REFERENCE) A spreadsheet was used to record individual, dyad, and group coding decisions.

(AUTHORS: this is the only place you mention trustworthiness. I am happy to see that addressed, but I think it would strengthen your manuscript and also add clarity for readers if you mention how this facilitated trustworthiness. In my opinion it is likely credibility and confirmability, so I have edited the sentence to reflect that level of detail. IF you feel that your work addressed any other of the four key criteria, feel free to add a sentence here, or elsewhere, to explain that. Also, I recommend that you cite a source for trustworthiness and the typical one that is cited as the original by Lincoln and Guba. If you agree, please provide that information and we will add a parenthetical citation and full reference information on the reference list. Thanks! Jackie)

Researchers used the particular survey question as the anchor for reference when assigning codes. For instance, no code was applied if the participant response had no mention of barriers for the question “What are barriers to adopting and/or implementing…” (e.g., “n/a” or “I don’t know” or “none”).

Due to the length of the data analysis for the qualitative portion and attrition of the committee members serving as researchers, the remaining researchers (i.e., the 3 authors) formed a triad to analyze the final question on general comments. The triad followed a comparable data analysis strategy in that each researcher coded individually and then as a triad came to consensus on final coding. Each researcher reviewed participant responses in each theme and subtheme within each question and selected exemplars that best represented the code assigned to the theme and subtheme. Then, through consensus the researchers decided which 3-4 exemplars to include as overall representation of the subtheme.

Results

Demographic Information
Most respondents were female with a mean age of 51.1 (SD = XX) (AUTHORS: can you provide a standard deviation to accompany your means?) years. Participants were predominantly white (XX%, n = XX) (AUTHORS: can you give a percentage and n to support this?), with 88% holding a BSN or higher nursing degree. Respondents were experienced clinicians (24.58 years practice as the mean, SD = XX) with 23% confirming advanced practice registered nurse credentials. All 50 states were represented with the highest percentage of respondents declaring their employment role as direct care and the work setting being mainly hospital based. (XX%, n = XX) (AUTHORS: can you give a percentage and n to support this?) Respondents identified that 35% had read the 2004 NSSP (first edition), 68% had read the 2010 (second edition), and only 48% had read the 2015 (third edition).

Emerging Themes
For the four open-ended questions asked, 59.2% (n = 994) of respondents completed at least one question related to barriers, strategies, outcomes, and general comments. Due to the volume of themes and subthemes, researchers generally limited the number of qualitative exemplars to three presented as direct quotes in a table format with associated number of codes. Respondent Comments captured coded excerpts from a broad or multi-perspective response.

Participant responses for each question ranged in length from one word to multiple sentences and paragraphs due to the unlimited character and word response fields in the survey. Consequently, multiple codes could be assigned to each participant response. Words could reflect a theme or subtheme and other words or phrases could support other categories or themes. Because of this, researchers had more codes than the number of participants. To capture the complexity of the multiple themes and some themes that emerged, below we first briefly introduce the emerging themes for each question. We conclude with individual links to supplemental documents that include many supporting quotations for each theme/something for readers who would like additional information.

(AUTHORS: I moved the paragraph above that was under Methods section to the Results section because it talks about what you found. I realize it’s a fine line and it also talks about how you analyzed, but you are noting that the question length ranged from X to X and then briefly stating how you dealt with that, so I think it is better placed in your results section. I also added a transition to describe the supplemental link information that you provided.

I also added subheadings and moved your discussion of the themes here as this is really results. You can’t discuss what the research means until you present what you found. There needs to be some introduction to your themes as they were found, which belongs under Results, and then discussion about what it means, which belongs under Discussion. You have a beautifully done Discussion section below, and moving your survey question results here and leaving the discussion to itself below will also highlight what you have written there for readers.

I also added links to your wonderful tables that we decided would be supplemental documents – these are also considered results because they are examples of what you found. Thanks very much for your work to add clarification to your findings – in my opinion it has significantly strengthened the readability of your article. Jackie)

Survey Question 1. Of the six themes that emerged from participant responses to the question, “What are barriers to adopting and/or implementing ANA’s Nursing Scope and Standards of Practice?” Systems was the major theme with subtheme, Awareness, receiving the greatest number of codes. For adoption to occur, diffusion of the idea, practice, or product (i.e., ANA NSSP document) begins with awareness (Rogers, 2003). Despite participants’ acknowledged awareness of the document, which was a requirement for study inclusion, they perceived awareness as a main barrier, particularly among those not affiliated with professional organizations. Time, another subtheme, described challenges related to reading, understanding, and applying the document. Availability of the document, both online and within institutions, was also a noted issue.

In the Standards theme, the subtheme Usability/Utility/Practicality provided perceptions about the academic nature of the document. Participants expressed challenges in applying vague or rigid standards to diverse nursing contexts. Issues with document length, lack of implementation plans, and the aspirational nature of standards also emerged. In the Setting theme, the subtheme Culture, whether individual, within the surrounding, or throughout an institution, was seen as a hindrance. In the Cognition theme, participants expressed the lack of Knowledge among the public and direct care nurses regarding the abilities and roles of nurses, and the NSSP document content. In the theme Professionalism, Responsibility/Accountability was something thatrevealed responses related to post-education lapses in practice, not keeping abreast of evolving standards, and a perception of nursing as a job rather than a profession. Lastly, in the Support theme, the subtheme Leaders, whether in academia or in healthcare settings, inadequately introduce the standards, are not competent to apply the document, or do not see it as foundational to nursing practice. Overall, the findings illustrated the multifaceted challenges and complexities surrounding the integration of the ANA NSSP document into individual and organizational professional practice in diverse contexts, and the need for targeted yet holistic strategies to address these identified obstacles.

Supplemental Table 1

Survey Question 2. Participant responses to the question, “What are strategies to adopting and/or implementing ANA’s Nursing Scope and Standards of Practice?” revealed six major themes, with the largest number of coded comments in the Communication/Dissemination theme. Make Accessible/Available was the largest subtheme, with comments that supported dissemination strategies utilizing employers, state licensure boards, and national organizations through mechanisms such as webinars, instructor-led classroom discussions, and social networks such as virtual book club meetings. The comments that informed the second largest theme, Educate, supported the need for stronger emphasis for nursing programs to incorporate the NSSP documents early and consistently throughout the entirety of the nursing curriculum.

The Leadership subtheme comprised the largest number of comments in the Demonstration theme. The top-down and bottom-up approach is highlighted, emphasizing the importance of involving political and healthcare leaders early and gaining their commitment throughout the process to support those at the bedside to integrate the NSSP document into practice. The Organizational Framework theme highlighted subthemes that suggest that the standards be incorporated as part of role expectations and yearly performance reviews. Using the NSSP document to craft policies and procedures and integrating it into the professional practice model will align the standards with clinical practice expectation as well.

In the Regulations theme, Licensure/Renewal was the largest subtheme with participant comments identifying great opportunities to highlight expectations for nurses to review the most current scope and standards, and to consider adding an attestation statement to the process of nurse licensure renewal. The Professional Organization theme had a large subtheme, Partnerships, that emphasized the role of ANA and other professional organizations to work together. Such collaboration could assist not only in disseminating NSSP content to a larger population of nurses but also provide occasions to benchmark with other organizations and educational opportunities related to the document. Overall, the comments in the strategies section underscored the diverse approaches required for successful integration of the ANA NSSP document into practice for meaningful use and impact.

Supplemental Table 2

Survey Question 3. Of the five themes that emerged from participant responses addressing “What are measurable outcomes from adopting and/or implementing ANA’s Nursing Scope and Standards of Practice?” the focus was mainly on the three themes of Nurse, Patient, and Organization. The Professional Practice subtheme of Nurse included outcomes associated with a clearer and deeper understanding of the nursing scope and practice, professional practice environment culture, and improved quality of critical thinking and decision-making. The Patient theme was represented primarily by three subthemes, including General, Quality/Safety Measures, and Satisfaction. These subthemes highlighted outcomes such as better-quality outcomes for patients and their families; reduced patient morbidity, mortality, and hospital acquired infections; and improved patient satisfaction scores. Components of the Organization theme were described by a subtheme of Systems/Structures, such as shared governance, nursing peer review committee, incentives for certification, and alignment of the nursing scope and standards with the electronic medical record.

Fewer participant responses were categorized under the Community/Public and Other Workforce themes. The General subtheme under the Community/Public theme included outcomes such as public awareness of roles and responsibilities and accountability of practicing nurses; one participant noted the Annual Gallup Poll on trusted professions. The General subtheme under the Other Workforce theme included outcomes such as increased night shift nurse participation in shared governance and improved professional behavior among peers and colleagues. The diversity and magnitude of the represented themes and subthemes associated with outcomes reaffirm existing opportunities for significant impact and influence of nursing in all aspects of healthcare.

Supplemental Table 3

Survey Question 4. Five themes emerged from participant responses to the survey item, “Comments about this survey and/or the ANA Nursing Scope and Standards of Practice.” Opinion was the major theme receiving the most codes. Some responses emphasized the potential elevation of nursing standards through individual awareness and adherence to the standards, while others expressed skepticism regarding their efficacy, highlighting the influence of state boards of nursing on practice. Sentiments toward ANA ranged from appreciation for its role as a professional resource to concerns about accessibility and awareness of its documents.

Respondents acknowledged RN accountability or lack thereof for these standards citing challenges in implementation amidst the demands of clinical practice.

In the Survey theme, participants expressed appreciation for the opportunity to contribute and express their views, emphasizing the importance of such research to identify needs and improve nursing knowledge. For the theme, Scope and Standards Document, participants expressed appreciation for the document, acknowledging its significance as a foundational resource for safe nursing practice and recommended regular review, feedback, and evolution to ensure ongoing relevance. In the theme Stimulating Professional Development and Action, participants expressed an interest in engaging with the document, with intentions ranging from seeking it out and reading it to reevaluating its contents. Lastly, in the Recommendations theme, participants emphasized the need for simplified, readily accessible versions of the document, integration into nursing programs, and practical implementation strategies, reflecting a desire for tangible outcomes.

Supplemental Table 4

Discussion

Although published research appears to lack information about specific diffusion and adoption of the ANA NSSP document, an examination of our study qualitative findings triggered a more refined literature review to enhance understanding for implications in today’s practice. Findings from the literature align with the qualitative themes and subthemes that emerged through participant comments in this research study. For example, the clinical research nurse scope and standard was used to develop continuing education for nurses about their professional roles (Herena et al., 2018). Similarly, continuing education and staff development activities were identified as effective strategies to facilitate implementation of changes in the practice environment related to genetic and genomic competencies for nursing informatics (McCormick & Calzone, 2017).

Exemplifying the message from Matthews (2012) that professional nursing organizations own the responsibility to advocate for the profession and its nurses, Gomez et al., (2011; 2017; 2022) embodied this responsibility within the nephrology specialty. Updated editions of the Nephrology Nursing Scope and Standards of Practice were referenced in each article, highlighting key points for scope of practice, standards of practice, and providing exemplars for practice integration. For example, Gomez et al. (2011) provided an example of how a nurse manager on a dialysis unit may integrate standards into corrective action plans, setting the expectation for improvement in competencies that align with the nephrology standards of practice. In another example, Gomez et al. (2017) stated that a nurse can use the standards in a professional presentation on dialysis complications to highlight the dialysis nurse is expected to “reduce environmental health risks to self, colleagues, and patients” (p. 23). While this literature is specific to the nephrology specialty, each article reiterates that its specialty NSSP aligns with the ANA NSSP, which supports the continued use and importance of ANA NSSP.

Robbins (2021) provided a summary of the updated fourth edition ANA NSSP but did not identify barriers, strategies, or outcomes for implementing the NSSP document. The author concluded that nurses should own or have access to the NSSP document which is “the backbone of the nursing profession” (p. 278). The author goes on to discuss the new standard, advocacy, which highlights the responsibility of nurses to advance and advocate for the nursing profession. Similar to other findings in the literature, Robbins (2021) supported the call to action for nursing organization advocacy as stated by Matthews (2012).

Kreitzer et al. (2022) took a different, yet similar, approach that showed how the fourth edition NSSP (ANA, 2021) elevated the importance of Integrative Nursing practices by updating the definition of nursing to emphasize the art and science of caring and the connectedness of all humanity. Frequent reference to whole-person care in the fourth edition NSSP also was highlighted by the researchers, correlating this to Integrative Nursing as “...a way of being, knowing, and doing that advances a whole health perspective to optimize well-being.” (p. 229). The article described exemplars of how various organizations created educational and clinical frameworks encompassing Integrative Nursing, highlighting the NSSPas a foundation and correlating improved outcomes such as decreased pain, decreased nausea, and reduced costs.

Expanding the literature search to include references older than five years revealed The Essential Guide to Nursing Practice, a detailed compilation for applying each standard in practice (White & O’Sullivan, 2012). Author: This citation is not in references This guide outlines four domains for each standard – education, administration, performance in quality improvement, and research – with thorough recommendations for application. However, referring to Rogers’ (2023) Author: This citation is not in references Diffusion of Innovation Model, observability in practice is still not well appreciated in this document.

Limitations
Several limitations in this study include respondent subjectivity, researcher bias, reliability and validity, generalizability, and considerations to applicability of analysis to current nursing workforce. While the qualitative nature of this research garners a richness in individual comments, it also relies on personal experience and therefore is highly subjective. Due to the mixed-methods approach to this research study, specifically the survey approach with non-identifiable information, it was impossible for the researchers to follow up with respondents to further explore deeper meaning of responses.

All researchers were members of the ANA Committee on Nursing Practice Standards and, in spite of the various backgrounds and relevant expertise, this commonality could present a potential for researcher bias. The varying depths of respondent comments could have influenced the interpretation of the data analyzed and added to researcher bias. Despite efforts to establish coding schemes and consensus, there could still be inherent subjectivity in interpretations and categorization of data, impacting reliability and validity of the findings. The represented specialties and educational level of participants and represented work settings was diverse, but the convenience sampling method may not be representative of the very diverse range of registered nurses, limiting the generalizability of the findings.

Analysis of data being published eight years after the survey can make the research dated by acceptable standards. However, the relevance of the topic justifies applicability and dissemination of findings due to the continued value of the NSSP document to the nursing profession. Respondent demographics of this 2016 study have differences with the results of a 2022 national nursing workforce survey that emphasized the COVID-19 pandemic having a significant impact on the nursing workforce (Smiley et al., 2023). The greatest differences noted between study respondents and 2022 workforce survey findings respectively include: median age – 51 years and 46 years; male RN participants – 6.4% and 11.2%; and primary work setting identified as hospital – 46.6% and 57.5%. Additionally, the 2022 workforce survey identified an increase in nurses with fewer than 10 years of experience, and who plan to retire in the next five years. It is difficult to predict whether the changing landscape of the nursing workforce would impact the awareness of, dissemination, and integration of the NSSP document.

Implications for Practice and Research
The main implication from these qualitative findings is that there is a need for targeted strategies to improve awareness, accessibility, and practical application of the NSSP document in diverse nursing contexts. A variety of approaches can be employed to make the document more accessible and understandable (e.g., tailoring to multigenerational nurses). The document needs to be incorporated into nursing program curricula early and consistently and address new shifts toward competency-based education. Nursing leaders play an essential role in awareness, adoption, and incorporation of this document into practice. Therefore, professional nursing organizations need to focus on assisting nurse leaders to achieve these goals is key. Entities employing nurses need to integrate the NSSP into systems and structures such as practice models, role expectations, and performance reviews to support professional practice and the practice environment.

Recommendations for future research based on the characterized barriers, strategies, outcomes, and general comments can be considered for further exploration. For example, communication/dissemination strategies for adopting and/or implementing the ANA NSSP represented 30% of comments in this category. Comparative studies might assess the influence and effectiveness of professional nursing organizations to promote NSSP adoption through various formats that explore variations in the approach to advocacy, education, and/or implementation support for the nursing discipline. Determining an improved integration if the NSSP document were to be readily available for free to all nurses is another topic for investigation. Exploring the roles of nurses and healthcare leaders to facilitate the adoption of the NSSP could include studies on leadership strategies, organizational support structures, and leadership attitudes towards the NSSP document. Other areas of study to consider are the impact of integrating standards in nursing program curricula with evaluation of outcomes, and technological innovations (e.g., the role of health information technology and electronic health records systems) to support integration of the NSSP document into nursing practice. Respondent comments in this research study identified barriers, strategies, and outcomes at all levels of nursing practice, from academia to government oversight, suggesting a call to action for more research on this topic. Such research can be accomplished in many specialty areas where nursing occurs.

Conclusion

In summary, the findings from this research study revealed rich perceptions and recommendations surrounding the adoption and integration of the ANA NSSP document in nursing practice, education, and policy. While participants expressed appreciation for the significance of the document in shaping nursing practice, concerns regarding its awareness, accessibility, and practicality are evident. This suggests the need for ongoing refinement and dissemination. Professional associations set standards to define the scope and standards of a profession and support its members (Summers & Bickford, 2017). Based on these research findings, ANA members have the opportunity to work with nursing organizations and governing bodies at state and national levels to ensure the NSSP is widely available, accessible, and easily understood by nursing professionals.

Likewise, the findings revealed a level of ownership and accountability for nurses as professionals to ensure their own awareness and understanding of the NSSP, supporting the need for nurses to recognize opportunities such as public comment periods when the NSSP is up for review and revision. Finally, a call for collaborative efforts among stakeholders, such as ANA and other nursing organizations at local, state, and national levels, can ensure the continual evolution, relevance, and integration of nursing standards in a dynamic healthcare landscape.

Acknowledgement: The research team was comprised of members of the ANA Committee on Nursing Practice Standards and included: Verna Sitzer, PhD, RN, CNS; Danette Culver, MSN, APRN, ACNS-BC, CCRN-K, RN-BC; Renee Gecsedi, MS, RN; Deedra Harrington, DNP, RN, APRN, ACNP-BC; Richard Henker, PhD, RN, CRNA, FAAN; Carla Lee, PhD, ARNP-BC, CNAA, FAAN; Carol J. Bickford, PhD, NI-BC, CPHIMS, FAMIA, FHIMSS, FAAN

Authors

(AUTHORS: We are now including author ORCID IDs, if available. This is not mandatory. If you have one, please provide it to us and it will be included. If you do not, we will remove that heading from under your bio. For articles with multiple authors, please provide this information to the corresponding author who can submit it with the galley proof edits.)

Danette Culver, MSN, APRN, ACNS-BC, CCRN-K
Email: Danette.culver@nortonhealthcare.org

Danette Culver is a Clinical Informatics Clinical Nurse Specialist at Norton Healthcare in Louisville, KY. She served on the American Nurses Association Committee on Nursing Practice Standards since 2015-2022. In addition to her work on this committee, Danette’s professional role allows her to advance nursing practice within Norton Healthcare’s system through evidence-based practice and process improvement strategies with an informatics area of focus.

Verna Sitzer, PhD, RN, CNS
Email: Verna.sitzer@sharp.com

Verna Sitzer, PHD, RN, CNS, Director of Professional Practice, Research, and Innovation at Sharp Memorial Hospital in San Diego, CA. She served on the American Nurses Association Committee on Nursing Practice for two terms. Her many years of experience as a clinical nurse specialist, Magnet program coordinator, and formal leader has provided ongoing opportunities to advocate for embedding professional practice standards into nursing practice structures, and processes.

Carol J. Bickford, PhD, NI-BC, CPHIMS, FAMIA, FHIMSS, FAAN
Email: Carol.bickford@ana.org

Carol J. Bickford, PhD, NI-BC, CPHIMS, FAMIA, FHIMSS, FAAN, American Nurses Association senior policy advisor, has facilitated the Committee on Nursing Practice Standards activities and operations for over 20 years. These efforts included extensive development and writing of scope and standards documents, oversight of the review and revision of four editions of Nursing: Scope and Standards of Practice, and extensive consultation and review of over 60 specialty nursing scope and standards development efforts.