The Professional Nursing Association's Role in Patient Safety

For the last 10 to 15 years concerns relative to the safety of patients and staff in the health care setting have been a major topic in the national health care arena. The restructuring of hospitals and the implementation of new policies and procedures to contain costs and manage care have exacerbated concerns about the industry’s abilities to assure safe, quality care (Lohr, 1990; Wunderlick, Sloan, & Davis, 1996). By the end of the 20^th century, cost-saving cuts in funding and organizational reactions to lower funding caused great concern among registered nurses (RNs) about patient safety. Such concerns were due to the decreasing nursing skill mix and decreasing number of registered nurses providing direct care to patients and clients. Such decreases in the number of RNs who provide direct patient care and supervise support staff, in relation to other nursing providers, can lead to fewer opportunities for patients to receive the appropriate assessments and interventions that can facilitate their recovery and even save their lives. The shift from a patient-focused environment to one dominated by monetary considerations has presented a dilemma – how do RNs maintain patient safety and strive for quality of care when the health care drivers are focused on medically-oriented technology, income generation, and cost shifting?

Judge Elbert Tuttle, in a speech given at Emory University in 1981 stated:

The professional man is in essence one who provides service. He has no goods to sell, no land to till. His only asset is himself. It turns out there is no right price for service, for what is a share of a man’s worth? If he does not contain the quality of integrity, he is worthless. If he does, he is priceless. The value is either nothing or it is infinite (as quoted by Patterson in The Washington Post, 1996, C1).

Merton (1958) has explained the essence of a professional association in stating: "The professional association is an organization of practitioners who judge one another as professionally competent and who have banded together to perform social functions which they cannot perform in their separate capacity as individuals" (Merton, p. 50).

There are many professional nursing associations in the United States, most of which have smaller, specialty-focused memberships. The American Nurses Association (ANA) differs from the specialty-focused associations in that it is a broad-based, multipurpose nursing organization. ANA members come from all nursing specialties, all practice sites, and all educational levels. It is generally recognized as the only all-purpose organization, and the largest representative of RNs in the United States.

Baszanger (1985) has stated that professional characteristics of any discipline include:

• A social mandate for the discipline.
• A professional society that maintains control over the standards of practice.
• A defined scope of practice and body of specialized knowledge.
• The ability to control entry into the discipline.
• Group members’ acceptance of a common ideology or societal mission.

One of the goals of the ANA is to promote patient safety.

This article describes the roles and activities of the ANA in this endeavor. However, nursing is faced with a multitude of forces, which, at times, place nursing associations in a position where what may be best for the public is not the best for the profession. In promoting safety, as in all of its activities, the ANA works to balance the needs and interests of the association, the profession, and the public so as to promote patient care. This article will discuss three specific roles of the ANA in promoting patient safety, specifically the roles of developing and disseminating foundation documents; lobbying and regulating; and advocating for patients and issues.

Developing and Disseminating Foundational Documents

The profession has given to ANA the tasks of articulating nursing’s commitment to society through its charge to serve as developer and guardian of the profession’s social policy statement, the standards and scope of nursing practice statement, and an ethical code. ANA serves as the guardian of these three foundational documents, but all RNs can contribute to the periodic revision of each. Thus, they are truly documents speaking with the voices of registered nurses in the United States. Merton (1958) has observed that it is the professional association’s manifest and latent social functions, rather than the structure designed to put these functions into effect, that give the profession reason to exist. He adds that professional associations usually state as their purpose an affirmation that they are designed to use their competencies for the welfare of the community in general and their specific clients in particular. The documents listed above, along with other policy and position statements developed by professional associations, articulate the profession’s beliefs on issues important to the public and the profession.

Nursing’s Social Policy Statement

The nursing profession’s commitment to society is articulated in Nursing’s Social Policy Statement (ANA, 2003b), a document maintained by ANA. The ANA states: "[this]...is a document that nurses can use as a framework for understanding nursing’s relationship with society and nursing’s obligation to those who receive nursing care" (ANA, 2003b, p.1). In addition it states: "...the authority for the practice of nursing is based on a social contract that acknowledges professional rights and responsibilities as well as mechanisms for public accountability" (ANA, 2003b, p. 3).

Society and the profession have evolved a series of understandings, which allow self-regulation to the profession with the expectation that the good of the public will be the principle goal of the profession. Donebedian (1976) writes:

Society grants the professions authority over functions vital to itself and permits them considerable autonomy in the conduct of their affairs. In return, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality in performance is at the heart of this relationship. It is the authentic hallmark of a mature profession. (p. 8).

With society’s imprimatur to self-regulate, the profession is challenged to ensure that its members honor that basic trust. Nursing, through its professional association, the ANA, addresses this trust.

Nursing’s Scope and Standards of Practice

This current (2003) scope and standards of practice statement, and its predecessor document, Standards of Clinical Nursing Practice (ANA, 1996), are the pivotal documents developed by the profession, claiming the areas of practice for RNs and establishing clear professional and clinical standards for RNs. This document describes the dimensions of the RN role in society. It is an articulation of the who, what, where, when, and why of nursing practice. As nursing, both as a profession and a discipline, matures and the health environment changes, scope statements can become outdated. They must be reviewed for possible revision at least every five years. Specialty associations also write their own scope statements, which describe their focused or specialty area of practice.

The scope and standards of practice statement includes the standards that guide patient care and professional behavior. The standards of care are authoritative statements that describe a competent level of clinical nursing practice demonstrated through assessment, diagnosis, outcomes identification, planning, and implementation of care. The standards of care are articulated through measurable criteria, which delineate the required clinical behaviors for all RNs in all places, at all times, and for all patients. The format and content of these standards were agreed upon by the various nursing professional associations. Specialty associations may add criteria to the standards and, occasionally, set a specific standard for their particular area.

The Code of Ethics for Nurses

The standards for professional performance are authoritative statements that describe a competent level of

behavior in the professional role (ANA, 1996). They relate directly to ANA’s Code of Ethics for Nurses with Interpretive Statements (ANA, 2001), a basic document which sets the ethical framework for the profession and its members. By establishing a code of ethics for RNs and reinforcing ethical behaviors through the standards for professional performance, the profession is providing its members with ethical standards to which they will be held and which can be used by RNs to document the profession’s expectations. These ethical standards also establish an ethical framework by which the public can hold the individual clinician and the profession accountable. Because the standards address basic expectations of professional practice and behavior, they are considered stable over time.

Lobbying for Legislation and Regulations

The RNs are the best advocates for themselves and their patients in a particular setting. The professional association, therefore, advocates for legislation and regulations which put into place the protections members of the profession need to meet the requirements of the code of ethics, standards of clinical practice, and state nurse practice acts. Legislative and regulatory approaches usually follow after other strategies have been tried and found lacking. The legislative and regulatory routes are slow and politicized, and the outcomes never assured. From a legislative standpoint, many issues do not lend themselves to the tedium of the political process; in addition, the details of some issues change so quickly it might be wise to avoid fixing them in the "stone" of law. The need for flexibility due to great variability in any issue argues against legislation or regulation as preferred solutions. For example, there is great discussion today (in 2003) about the wisdom of legislating nurse-patient staffing ratios. Legislating these ratios may be unwise since each clinical site is variable, some much more than others. Therefore, it is questionable whether legislation allows enough flexibility for staffing decisions.

Even though there are instances where one might question the use of legislation or regulations to address an issue, there are some critical instances for which the political process is either the preferred route or last way to effect change. Two major examples of the value of legislative and regulatory involvement by professional associations are needle stick protections and whistle blower protections. Both of these issues had been identified as major problems to hospitals and state governments over the years, yet no action was taken. Since no other groups had the expressed will to protect the public’s health and well-being in these areas, professional nursing associations pursued them. Bills were vigorously supported by these nursing associations, who enlisted other health care professionals and the public in their efforts. These two major dangers to the RN and the public – the spread of blood-borne disease and the prohibition of the patient advocacy role of the RN – were major health and safety action issues for professional nursing associations.

Regulation of RNs at the state level is the purview of each state Board of Nursing (the Board). The Board addresses issues, which impact on protection of the public’s well-being. Such issues are usually legal or regulatory in nature. In many states, members of the Board are political appointees of that state’s governor. Qualifications and nursing philosophies of members vary greatly, but their view of the role of government in regulating the profession is usually consistent with the appointing administration’s philosophy and political will. Boards of Nursing are independent of professional associations. Their responsibility is to protect the public, not the profession. Indeed, in many states, Boards of Nursing and professional associations collaborate to protect the public. However, when the professional association perceives an issue as necessary for the advancement or protection of the profession, and the Board does not see it as protective of the public, the two groups may diverge. As with all relationships, stress can occur when the goal of protecting the public is approached differently by each of the two groups.

At the national level, the trade association for the State Boards of Nursing is the National Council of State Boards of Nursing (NCSBN). The NCSBN is essentially the advocacy group for Boards of Nursing. Professional associations attempt to work with the NCSBN as much as possible, yet, there are and will continue to be points of divergence.

The ANA Nursing Scope and Standards of Practice (2003a) and the Code of Ethics for Nurses (2001) have legal standing because they are promulgated by the profession and have been cited in case law. These documents are viewed by the judicial system as the profession’s expectations of all of its practitioners. Legal recognition can also be gained for such documents when cited in state nurse practice acts. The national professional association can serve as a resource for state associations as they seek to add such references to their nurse practice acts and to legislators and regulators as they attempt to find ways to protect society’s well-being.

In states where collective bargaining is a means of worker–management communication, negotiated labor-management contracts can cite such professional documents as the professional standards for behavior and practice. In fact, this has been done not only in the collective bargaining context but also in the context of non-unionized "negotiations" between staff and management. More recently, the trend towards collection of nursing-sensitive indicators and their sharing of data related to these indicators with the nursing staff has been a new point for negotiating.

An important role of state boards of nursing is to regulate the education of RNs. This education should include not only clinical content but also the meaning and use of the major documents of the profession, the legal mandates identified in the state nurse practice act, the policies of the employer, and any labor contracts or other state laws affecting practice. The state boards of nursing also have legal and regulatory responsibility and authority for nursing practice. This includes the authority to protect the public’s well-being through licensing and enforcement of state nurse practice acts. In contrast, the professional association, as the repository of clinical expertise, is limited to the use of its positional authority to influence the association’s membership.

Advocating for Patients and Issues

The profession, through the ANA, advocates for patients and nursing issues in various ways. Two important approaches include the documentation and analysis of patient outcomes and the promotion of accreditation and credentialing. Both serve to promote patient safety.

Documentation of Patient Outcomes

Over the last 20 years, a cry has arisen within health care to use empirical data to prove the need or usefulness of requested resources. The anecdotes of years gone by are no longer adequate to achieve desired goals. In the last seven years, ANA has developed the National Database for Nursing Quality Indicators (NDNQI) www.nursingquality.org/ndnqi/ and nursing-sensitive indicators as a means of quantitatively evaluating nursing practice and its impact on patient care. Although "quality" and "safety of care" have been major issues for discussion in the health care community for some time, most emphasis has been on the procedures or products for which reimbursement is obtained or utilization monitored. This myopic focus resulted in data almost exclusively on medical care and technology costs, rather than on care received and associated outcomes. Following the health care industry’s ongoing focus on cost and quality of care, ANA has begun to stress the impact of nursing care on patient outcomes and moved these into the "national limelight", where issues receive the attention they need to be incorporated into funding and policy mandates.

Collection of nursing-sensitive data at the nursing unit level offers staff nurses, as well as management, the opportunity to identify both exceptional practices and less than desired practices. By the study of exceptional practices, nursing is offered the opportunity to learn and to disseminate that learning to improve patient care. ANA’s standards of nursing practice and ethical code require RNs to evaluate their practice. Using ANA’s indicators to evaluate care at the nursing unit level helps RNs meet the standard of evaluating their practice.

The collection of indicator data

specifically targeted at nursing care and its impact on patient outcomes enhances our opportunity to empirically study the complexities of the patient care system and contributes to the expansion of nursing and patient care knowledge. The professional association, as the leader in such an effort, helps drive the profession to examine its practices in relation to its mandate from the public. Raising the visibility of RN practice and its importance to patient care outcomes has the potential to elevate the status and importance of RNs in the eyes of the public and the health care industry. Hopefully the sequela of this awareness will be that RNs’ contributions to patient care will become an ongoing part of the evaluative process for improving patient care. The increased visibility associated with collecting indicator data helps non-nurse health care colleagues understand the importance of RN roles and reminds RNs of their many contributions to the health care system and the people it serves.

Accreditation and Credentialing Mechanisms

Professional documents may provide the framework within which each RN should function, yet there must also be mechanisms to assure that graduates of nursing education programs are adequately prepared and, as RNs, remain competent during their careers. For these purposes, there are accrediting organizations for basic and advanced educational programs (i.e., National League for Nursing Accrediting Company and the American Association of Colleges of Nursing Commission on Collegiate Nursing Education); accreditors and approvers of continuing education (CE) programs (i.e., American Nurses Credentialing Center); and licensers and certifiers for RNs (State Boards of Nursing, American Nurses Credentialing Center, National Association of Pediatric Nurse Associates and Practitioners, and other professional specialty organizations. These organizations have the responsibility of providing evaluations based on standards that assure the quality of the educational program or the clinician. Thus nursing, through many mechanisms, and at many levels of the public and private sector, works through its professional associations to fulfill its commitment to protect both the public and its own practitioners.

Conclusion

Nursing is a proud and diverse profession within a health care environment, yet a profession that remains, to a large extent, dominated by administrators, physicians, and payers. Centuries of medical focus have marginalized the contributions of RN practice and its contributions to patient care. Although it has been recognized for decades that quality educational programs, programs for recognition of expertise, and the assurance of clinical competency are necessary, RNs have not been appreciated for their contributions to desired patient outcomes. Although the debate still rumbles, the relationship between quality of care provided by RNs and quality patient outcomes is becoming clearer. Professional associations serve the role of advocate for the profession and for those served by the profession’s members in this turbulent, cost-driven, cost-shifting health care environment. The professional association serves as the eyes, ears, mouth, and conscience for the profession’s past, present, and future. It strives to assure a professional nurturing environment with appropriate resources, and a health care system that incorporates the expertise of all providers in a decision-making process centered on the patient. It does so by developing and disseminating foundational documents, lobbying and regulating, and advocating for patients and issues. The nursing profession’s commitment to serve the public enhances safe patient care, which is of utmost importance to the profession and its members.

Author

Patricia A. Rowell, PhD, RN, CNP
e-mail: prowell@ana.org

Patricia Rowell, PhD, RN, CNP is the senior policy fellow in the American Nurses Association (ANA) Department of Nursing Practice charged with overseeing Nursing’s Safety and Quality Initiative, and mental health and maternal-child policy issues. From 1992 until 1998, Dr. Rowell also oversaw the development of nursing clinical practice standards and guidelines. She has worked for the ANA in the areas of policy and research since 1992. Her educational background includes BS (science), BSN, MSN (pediatric nursing) with Pediatric Nurse Practitioner (PNP) certification, and a PhD (health services administration and research). Her doctoral study and research were in the areas of quality measurement and improvement. Dr. Rowell’s varied clinical background includes work in the emergency room, in-patient psychiatry, public and home (maternal-child) health, and ambulatory (PNP) and inpatient pediatrics. She has also worked as a health services researcher, and has numerous publications and presentations on health care and nursing.