1. Health Care Settings & Team
Open Resources for Nursing (Open RN) and Amy Ertwine
Health Care Settings
There are several levels of health care including primary, secondary, and tertiary care. Each of these levels focuses on different aspects of health care and is typically provided in different settings.
Primary Care
Primary care promotes wellness and prevents disease. This care includes health promotion, education, protection (such as immunizations), early disease screening, and environmental considerations. Settings providing this type of health care include physician offices, public health clinics, school nursing, and community health nursing.
Secondary care
Secondary care occurs when a person has contracted an illness or injury and requires medical care. Secondary care is often referred to as acute care. Secondary care can range from uncomplicated care to repair a small laceration or treat a strep throat infection to more complicated emergent care such as treating a head injury sustained in an automobile accident. Whatever the problem, the client needs medical and nursing attention to return to a state of health and wellness. Secondary care is provided in settings such as physician offices, clinics, urgent care facilities, or hospitals. Specialized units include areas such as critical care, burn units, neurosurgery, cardiac surgery, and transplant services.
Tertiary Care
Tertiary care addresses the long-term effects from chronic illnesses or conditions with the purpose to restore a client’s maximum physical and mental function. The goal of tertiary care is to achieve the highest level of functioning possible while managing the chronic illness. For example, a client who falls and fractures their hip will need secondary care to set the broken bones, but may need tertiary care to regain their strength and ability to walk even after the bones have healed. Clients with incurable diseases, such as dementia, may need specialized tertiary care to provide support they need for daily functioning. Tertiary care settings include rehabilitation units, assisted living facilities, adult day care, skilled nursing units, home care, and hospice centers.
Health Care Team
No matter the setting, quality health care requires a team of health care professionals collaboratively working together to deliver holistic, individualized care. Nursing students must be aware of the roles and contributions of various health care team members. The health care team consists of health care providers, nurses (licensed practical nurses, registered nurses, and advanced practice registered nurses), unlicensed assistive personnel, and a variety of interprofessional team members.
Health Care Providers
Providers are responsible for ordering diagnostic tests such as blood work and X-rays, diagnosing a client’s medical condition, developing a medical treatment plan, and prescribing medications. In a hospital setting, the medical treatment plan developed by a provider is communicated in the “History and Physical” component of the client’s medical record with associated prescriptions (otherwise known as “orders”). Prescriptions or “orders” include diagnostic and laboratory tests, medications, and general parameters regarding the care that each client is to receive. Nurses should respectfully clarify prescriptions they have questions or concerns about to ensure safe client care. Providers typically visit hospitalized clients daily in what is referred to as “rounds.” It is helpful for nurses and nursing students to attend provider rounds for their assigned clients to be aware of and provide input regarding the current medical treatment plan, seek clarification, or ask questions. This helps to ensure that the provider, nurse, and client have a clear understanding of the goals of care and minimizes the need for follow-up phone calls.
Nurses
There are three levels of nurses as defined by each state’s Nurse Practice Act: Licensed Practical Nurse/Vocational Nurse (LPN/LVN), Registered Nurse (RN), and Advanced Practice Registered Nurse (APRN).
Licensed Practical/Vocational Nurses
The National Council of State Boards of Nursing (NCSBN) defines a licensed practical nurse (LPN) as, “An individual who has completed a state-approved practical or vocational nursing program, passed the NCLEX-PN examination, and is licensed by a state board of nursing to provide client care.”[1] In some states, the term licensed vocational nurse (LVN) is used. LPNs/LVNs typically work under the supervision of a registered nurse, advanced practice registered nurse, or physician.[2] LPNs/LVNs typically collect client assessment information, administer medications, and perform nursing procedures according to their scope of practice in that state. The Open RN Nursing Skills, 2e textbook discusses the skills and procedures that LPNs frequently perform in Wisconsin. See the following box for additional details about the scope of practice of the Licensed Practical Nurse in Wisconsin.
Scope of Practice for Licensed Practical Nurses in Maryland
Registered Nurses
The NCSBN defines a Registered Nurse (RN) as “An individual who has graduated from a state-approved school of nursing, passed the NCLEX-RN examination and is licensed by a state board of nursing to provide client care.”[3] Registered Nurses (RNs) use the nursing process as a critical thinking model as they make decisions and use clinical judgment regarding client care. The nursing process is discussed in more detail in the “Nursing Process” chapter of this book. RNs may be delegated tasks from providers or may delegate tasks to LPNs and UAPs with supervision. See the following box for additional details about the scope of practice for Registered Nurses in the state of Wisconsin.
Scope of Practice for Registered Nurses in Maryland
Advanced Practice Registered Nurses
Advanced Practice Registered Nurses (APRN) are defined by the NCSBN as an RN who has a graduate degree and advanced knowledge. There are four categories of Advanced Practice Registered Nurses: Certified Nurse-Midwife (CNM), Clinical Nurse Specialist (CNS), Certified Nurse Practitioner (CNP), and Certified Registered Nurse Anesthetist (CRNA). APRNs can diagnose illnesses and prescribe treatments and medications. Additional information about advanced nursing degrees and roles is provided in the box below.
Advanced Practice Nursing Roles[4]
Nurse Practitioners: Nurse practitioners (NPs) work in a variety of settings and complete physical examinations, diagnose and treat common acute illness and manage chronic illness, order laboratory and diagnostic tests, prescribe medications and other therapies, provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance, and refer clients to other health professionals and specialists as needed. In many states, NPs can function independently and manage their own clinics, whereas in other states physician supervision is required. NP certifications include, but are not limited to, Family Practice, Adult-Gerontology Primary Care and Acute Care, and Psychiatric/Mental Health.
To read more about NP certification, visit Nursing World’s Our Certifications web page.
Clinical Nurse Specialists: Clinical Nurse Specialists (CNS) practice in a variety of health care environments and participate in mentoring other nurses, case management, research, designing and conducting quality improvement programs, and serving as educators and consultants. Specialty areas include, but are not limited to, Adult/Gerontology, Pediatrics, and Neonatal.
To read more about CNS certification, visit National Association of Clinical Nurse Specialist’s What is a CNS? web page.
Certified Registered Nurse Anesthetists: Certified Registered Nurse Anesthetists (CRNAs) administer anesthesia and related care before, during, and after surgical, therapeutic, diagnostic, and obstetrical procedures, as well as provide airway management during medical emergencies. CRNAs deliver more than 65 percent of all anesthetics to clients in the United States. Practice settings include operating rooms, dental offices, and outpatient surgical centers.
To read more about CRNA certification, visit National Board of Certification & Recertification for Nurse Anesthetist’s website.
Certified Nurse Midwives: Certified Nurse Midwives provide gynecological exams, family planning advice, prenatal care, management of low-risk labor and delivery, and neonatal care. Practice settings include hospitals, birthing centers, community clinics, and client homes.
To read more about CNM certification, visit the American Midwifery Certification Board website.
Unlicensed Assistive Personnel
Unlicensed Assistive Personnel (UAP) are defined by the NCSBN as, “Any unlicensed person, regardless of title, who performs tasks delegated by a nurse. This includes certified nursing aides/assistants (CNAs), patient care assistants (PCAs), patient care technicians (PCTs), state tested nursing assistants (STNAs), nursing assistants-registered (NA/Rs), or certified medication aides/assistants (MA-Cs). Certification of UAPs varies between jurisdictions.”[5]
CNAs, PCAs, and PCTs in Wisconsin generally work in hospitals and long-term care facilities and assist clients with daily tasks such as bathing, dressing, feeding, and toileting. They may also collect client information such as vital signs, weight, and input/output as delegated by the nurse. The RN remains accountable that delegated tasks have been completed and documented by the UAP.
Interprofessional Team Members
Nurses, as the coordinator of a client’s care, continuously review the plan of care to ensure all contributions of the multidisciplinary team are moving the client toward expected outcomes and goals. The roles and contributions of interprofessional health care team members are further described in the following box.
Interprofessional Team Member Roles[6]
Dieticians: Dieticians assess, plan, implement, and evaluate interventions, including those relating to dietary needs of those clients who need regular or therapeutic diets. They also provide dietary education and work with other members of the health care team when a client has dietary needs secondary to physical disorders such as difficulty swallowing.
Occupational Therapists (OT): Occupational therapists assess, plan, implement, and evaluate interventions, including those that facilitate the client’s ability to achieve their highest possible level of independence in their activities of daily living such as bathing, grooming, eating, and dressing. They also provide clients with adaptive devices such as long shoehorns so the client can put their shoes on, sock pulls so they can independently pull on socks, adaptive silverware to facilitate independent eating, grabbers so the client can pick items up from the floor, and special devices to manipulate buttoning so the person can dress and button their clothing independently. OTs assess the home for safety and the need for assistive devices when the client is discharged home. They may recommend modifications to the home environment such as ramps, grab rails, and handrails to ensure safety and independence. OTs practice in all health care environments, including the home, hospital, and rehabilitation centers.
Pharmacists: Pharmacists ensure the safe prescribing and dispensing of medication and are a vital resource for nurses with questions or concerns about medications they are administering to clients. Pharmacists ensure that clients not only get the correct medication and dosing, but also have the guidance they need to use the medication safely and effectively.
Physical Therapists (PT): Physical therapists are licensed health care professionals who assess, plan, implement, and evaluate interventions, including those related to the client’s functional abilities in terms of their strength, mobility, balance, gait, coordination, and joint range of motion. They supervise prescribed exercise activities according to a client’s condition and also provide and teach clients how to use assistive aids like walkers and canes and how to perform exercise regimens. Physical therapists practice in all health care environments, including the home, hospital, and rehabilitation centers.
Podiatrists: Podiatrists provide care and services to clients who have foot problems. They often work with clients who have diabetes to clip toenails and provide foot care to prevent complications.
Prosthetists: Prosthetists design, fit, and supply the client with an artificial body part such as a leg or arm prosthesis. They adjust prosthesis to ensure proper fit, comfort, and functioning.
Psychologists and Psychiatrists: Psychologists and psychiatrists provide mental health and psychiatric services to clients with mental health disorders and provide psychological support to family members and significant others as indicated.
Respiratory Therapists: Respiratory therapists treat respiratory-related conditions in clients. Their specialized respiratory care includes managing oxygen therapy; drawing arterial blood gases; managing clients on specialized oxygenation devices such as mechanical ventilators, CPAP, and Bi-PAP machines; administering respiratory medications like inhalers and nebulizers; intubating clients; assisting with bronchoscopy and other respiratory-related diagnostic tests; performing pulmonary hygiene measures like chest physiotherapy; and serving an integral role in providing respiratory support.
Social Workers: Social workers counsel clients and provide psychological support, help set up community resources according to clients’ financial needs, and serve as part of the team that ensures continuity of care after the person is discharged.
Speech Therapists: Speech therapists assess, diagnose, and treat communication and swallowing disorders. For example, speech therapists help clients with a disorder called expressive aphasia. They also assist clients with using word boards and other electronic devices to facilitate communication. They assess clients with swallowing disorders called dysphagia and treat them in collaboration with other members of the health care team including nurses, dieticians, and health care providers.
Ancillary Department Members: Nurses also work with ancillary departments such as laboratory and radiology departments.
- Clinical laboratory departments provide a wide range of laboratory procedures that aid health care providers to diagnose, treat, and manage clients. These laboratories are staffed by medical technologists who test biological specimens collected from clients. Examples of laboratory tests performed include blood tests, blood banking, cultures, urine tests, and histopathology (changes in tissues caused by disease).[7]
- Radiology departments use imaging to assist providers in diagnosing and treating diseases seen within the body. They perform diagnostic tests such as X-rays, CTs, MRIs, nuclear medicine, PET scans, and ultrasound scans.
Chain of Command
Nurses rarely make client decisions in isolation, but instead consult with other nurses and interprofessional team members. Concerns and questions about client care are typically communicated according to that agency’s chain of command. In the military, chain of command refers to a hierarchy of reporting relationships – from the bottom to the top of an organization – regarding who must answer to whom. The chain of command not only establishes accountability, but also lays out lines of authority and decision-making power. The chain of command also applies to health care. For example, a registered nurse in a hospital may consult a “charge nurse,” who may consult the “nurse supervisor,” who may consult the “director of nursing,” who may consult the “vice president of nursing.” In a long-term care facility, a licensed practical/vocational nurse typically consults the registered nurse/charge nurse, who may consult with the director of nursing. Nursing students should always consult with their nursing instructor regarding questions or concerns about client care before “going up the chain of command.”
Nurse Specialties
Registered nurses can obtain several types of certifications as a nurse specialist. Certification is the formal recognition of specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty. See the following box for descriptions of common nurse specialties.
Common Nurse Specialties
Critical Care Nurses provide care to clients with serious, complex, and acute illnesses or injuries that require very close monitoring and extensive medication protocols and therapies. Critical care nurses most often work in intensive care units of hospitals.
Public Health Nurses work to promote and protect the health of populations based on knowledge from nursing, social, and public health sciences. Public health nurses most often work in municipal and state health departments.
Home Health/Hospice Nurses provide a variety of nursing services for chronically ill clients and their caregivers in the home, including end-of-life care.
Occupational/Employee Health Nurses provide health screening, wellness programs and other health teaching, minor treatments, and disease/medication management services to people in the workplace. The focus is on promotion and restoration of health, prevention of illness and injury, and protection from work-related and environmental hazards.
Oncology Nurses care for clients with various types of cancer, administering chemotherapy and providing follow-up care, teaching, and monitoring. Oncology nurses work in hospitals, outpatient clinics, and clients’ homes.
Perioperative/Operating Room Nurses provide preoperative and postoperative care to clients undergoing anesthesia or assist with surgical procedures by selecting and handling instruments, controlling bleeding, and suturing incisions. These nurses work in hospitals and outpatient surgical centers.
Rehabilitation Nurses care for clients with temporary and permanent disabilities within inpatient and outpatient settings such as clinics and home health care.
Psychiatric/Mental Health Nurses specialize in mental and behavioral health problems and provide nursing care to individuals with psychiatric disorders. Psychiatric nurses work in hospitals, outpatient clinics, and private offices.
School Nurses provide health assessment, intervention, and follow-up to maintain school compliance with health care policies and ensure the health and safety of staff and students. They administer medications and refer students for additional services when hearing, vision, and other issues become inhibitors to successful learning.
Telenursing refers to providing nursing care remotely using information and communication technology. Nursing care may include client education, support, health assessment and evaluation, and triage. While telenursing is not a specialty, it is provided in several specialty areas such as Critical Care and Emergency Departments. It is also provided in outpatient environments and encourages increased client interactions, especially in underserved rural areas.[8]
Other common specialty areas include a life span approach across health care settings and include maternal-child, neonatal, pediatric, and gerontological nursing.[9]
- NCSBN. https://www.ncsbn.org/ ↵
- NCSBN. https://www.ncsbn.org/index.htm ↵
- NCSBN. https://www.ncsbn.org/index.htm ↵
- Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press. https://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-health ↵
- NCSBN. https://www.ncsbn.org/index.htm ↵
- Burke, A. (2020, January 15). Collaboration with interdisciplinary team: NCLEX-RN. RegisteredNursing.org. https://www.registerednursing.org/nclex/collaboration-interdisciplinary-team/#collaborating-healthcare-members-disciplines-providing-client-care ↵
- This work is a derivative of StatPearls by Bayot and Naidoo and licensed under CC BY 4.0 ↵
- Khraisat, O. M. A., Al-Bashaireh, A. M., & Alnazly, E. (2023). Telenursing implications for future education and practice: Nursing students' perspectives and knowledge from a course on child health. PLoS One, 18(11), e0294711. https://doi.org/10.1371/journal.pone.0294711. ↵
- Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press. https://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-health ↵
Legal Considerations
As discussed earlier in this chapter, nurses can be reprimanded or have their licenses revoked for not appropriately following the Nurse Practice Act in the state they are practicing. Nurses can also be held legally liable for negligence, malpractice, or breach of client confidentiality when providing client care.
Negligence and Malpractice
Negligence is a general term that denotes conduct lacking in due care, carelessness, and a deviation from the standard of care that a reasonable person would use in a particular set of circumstances.[1] Malpractice is a more specific term that looks at a standard of care, as well as the professional status of the caregiver. [2]
To prove negligence or malpractice, the following elements must be established in a court of law[3]:
- Duty owed the client
- Breach of duty owed the client
- Foreseeability
- Causation
- Injury
- Damages
To avoid being sued for negligence or malpractice, it is essential for nurses and nursing students to follow the scope and standards of practice care set forth by their state’s Nurse Practice Act; the American Nurses Association; and employer policies, procedures, and protocols to avoid the risk of losing their nursing license. Examples of a nurse's breach of duty that can be viewed as negligence includes the following:[4]
- Failure to Assess: Nurses should assess for all potential nursing problems/diagnoses, not just those directly affected by the medical disease. For example, all clients should be assessed for fall risk and appropriate fall precautions implemented.
- Insufficient monitoring: Some conditions require frequent monitoring by the nurse, such as risk for falls, suicide risk, confusion, and self-injury.
- Failure to Communicate:
- Lack of documentation: A basic rule of thumb in a court of law is that if an assessment or action was not documented, it is considered not done. Nurses must document all assessments and interventions, in addition to the specific type of client documentation called a nursing care plan.
- Lack of provider notification: Changes in client condition should be urgently communicated to the health care provider based on client status. Documentation of provider notification should include the date, time, and person notified and follow-up actions taken by the nurse.
- Failure to Follow Protocols: Agencies and states have rules for reporting certain behaviors or concerns. For example, a nurse is considered a mandatory reporter by law and required to report suspicion of abuse or neglect of a child based on data gathered during an assessment.
Patient Self Determination Act
The Patient Self Determination Act (PSDA) of 1990 is an amendment made to the Social Security Act that requires health care facilities to inform clients of their right to be involved in their medical care decisions. This law specifically applies to facilities accepting Medicare or Medicaid funding but is considered a right of all clients regardless of their method of reimbursement.
Under the PSDA, clients must also be asked about their advance directives and care wishes. Clients must be provided with teaching about advance directives, appointment of an agent or surrogate in the event they become incapacitated, and their right to self-determination. Conversations about these topics and clients wishes must be documented in the medical record. It is considered an ethical duty of nurses and other health care professionals to ensure clients are aware and understand these healthcare-associated rights.[5]
Informed Consent
Informed consent is written consent voluntarily signed by a client who is competent and understands the terms of the consent without any form of coercion. In the event the client is a minor or deemed incompetent to make their own decisions, a parent or legal guardian signs the informed consent.[6]
Informed consent is crucial for upholding the client's right for self-determination. Informed consent provides documentation signed by the client of their understanding of health care being provided; its benefits, risks, potential complications; reasonable alternatives to treatment; and the right to withdraw consent. It is the health care provider's responsibility to fully discuss the treatment, procedure, or other health care action being proposed that requires consent. The nurse often signs as a witness to the client's signature on the form, affirming that person signed the form. However, it is not the nurse's responsibility or role to provide information. If the client (or their parent/legal guardian) expresses questions, concerns, or lack of understanding, the nurse has an ethical responsibility to notify the provider and advocate for further discussion before signing the form.[7]
In emergency situations where the delay to obtain consent would cause undue harm to the client, verbal or telephone consent may be temporarily obtained that is valid for no more than ten days. Verbal consent and the reason for verbal consent must be documented in the medical record by the provider.[8]
See the following box for examples of situations requiring informed consent in the state of Wisconsin according to the Wisconsin Department of Health Services.
Examples of Situations Requiring Informed Consent[9]
- Receipt of medications and/or treatment, including psychotropic medications (unless court-ordered)
- Undergoing customary treatment techniques and procedures
- Participation in experimental research
- Undergoing psychosurgery or other psychological treatment procedures
- Release of treatment records
- Videorecording
- Performance of labor beneficial to the facility
Confidentiality
In addition to negligence and malpractice, confidentiality is a major legal consideration for nurses and nursing students. Patient confidentiality is the right of an individual to have personal, identifiable medical information, referred to as their protected health information (PHI), protected and known only by those health care team members directly providing care to them. This right is protected by federal regulations called the Health Insurance Portability and Accountability Act (HIPAA). HIPAA was enacted in 1996 and was prompted by the need to ensure privacy and protection of personal health records and data in an environment of electronic medical records and third-party insurance payers. There are two main sections of HIPAA law, the Privacy Rule and the Security Rule. The Privacy Rule addresses the use and disclosure of individuals' health information. The Security Rule sets national standards for protecting the confidentiality, integrity, and availability of electronically protected health information. HIPAA regulations extend beyond medical records and apply to client information shared with others. Therefore, all types of client information should only be shared with health care team members who are actively providing care to them.
How do HIPAA regulations affect you as a student nurse? You are required to adhere to HIPAA guidelines from the moment you begin to provide client care. Nursing students may be disciplined or expelled by their nursing program for violating HIPAA. Nurses who violate HIPAA rules may be fired from their jobs or face lawsuits. See the following box for common types of HIPAA violations and ways to avoid them.
Common HIPAA Violations and Ways to Avoid Them[10]
- Gossiping in the hallways or otherwise talking about clients where other people can hear you. It is understandable that you will be excited about what is happening when you begin working with clients and your desire to discuss interesting things that occur. As a student, you will be able to discuss client care in a confidential manner behind closed doors with your instructor. However, as a health care professional, do not talk about clients in the hallways, elevator, breakroom, or with others who are not directly involved with that client’s care because it is too easy for others to overhear what you are saying.
- Mishandling medical records or leaving medical records unsecured. You can breach HIPAA rules by leaving your computer unlocked for anyone to access or by leaving written client charts in unsecured locations. You should never share your password with anyone else. Make sure that computers are always locked with a password when you step away from them and paper charts are closed and secured in an area where unauthorized people don’t have easy access to them. NEVER take records from a facility or include a client's name on paperwork that leaves the facility.
- Illegally or unauthorized accessing of client files. If someone you know, like a neighbor, coworker, or family member is admitted to the unit you are working on, do not access their medical record unless you are directly caring for them. Facilities have the capability of tracing everything you access within the electronic medical record and holding you accountable. This rule holds true for employees who previously cared for a client as a student; once your shift is over as a student, you should no longer access that client’s medical records.
- Sharing information with unauthorized people. Anytime you share medical information with anyone but the client themselves, you must have written permission to do so. For instance, if a husband comes to you and wants to know his spouse’s lab results, you must have permission from his spouse before you can share that information with him. Just confirming or denying that a client has been admitted to a unit or agency can be considered a breach of confidentiality. Furthermore, voicemails should not be left regarding protected client information.
- Information can generally be shared with the parents of children until they turn 18, although there are exceptions to this rule if the minor child seeks birth control, an abortion, or becomes pregnant. After a child turns 18, information can no longer be shared with the parent unless written permission is provided, even if the minor is living at home and/or the parents are paying for their insurance or health care. As a general rule, any time you are asked for client information, check first to see if the client has granted permission.
- Texting or e-mailing regarding client information on an unencrypted device. Only use properly encrypted devices that have been approved by your health care facility for e-mailing or faxing protected client information. Also, ensure that the information is being sent to the correct person, address, or phone number.
- Sharing information on social media. Never post anything on social media that has anything to do with your clients, the facility where you are working or have clinical, or even how your day went at the agency. Nurses and other professionals have been fired for violating HIPAA rules on social media.[11],[12],[13]
Social Media Guidelines
Nursing students, nurses, and other health care team members must use extreme caution when posting to Facebook, Instagram, Twitter, Snapchat, and other social media sites. Information related to clients, client care, and/or health care agencies should never be posted on social media; health care team members who violate this guideline can lose their jobs and may face legal action and students can be disciplined or expelled from their nursing program. Be aware that even if you think you are posting in a private group, the information can become public.
The American Nurses Association (ANA) has established the following principles for nurses using social media:[14]
- Nurses must not transmit or place online individually identifiable client information.
- Nurses must observe ethically prescribed professional client-nurse boundaries.
- Nurses should understand that clients, colleagues, organizations, and employers may view postings.
- Nurses should take advantage of privacy settings and seek to separate personal and professional information online.
- Nurses should bring content that could harm a client’s privacy, rights, or welfare to the attention of appropriate authorities.
- Nurses should participate in developing organizational policies governing online conduct.
In addition to these principles, the ANA has also provided these tips for nurses and nursing students using social media:[15]
- Remember that standards of professionalism are the same online as in any other circumstance.
- Do not share or post information or photos gained through the nurse-client relationship.
- Maintain professional boundaries in the use of electronic media. Online contact with clients blurs this boundary.
- Do not make disparaging remarks about clients, employers, or coworkers, even if they are not identified.
- Do not take photos or videos of clients on personal devices, including cell phones.
- Promptly report a breach of confidentiality or privacy.
Read more about the ANA's Social Media Principles.
Code of Ethics
In addition to legal considerations, there are also several ethical guidelines for nursing care.
There is a difference between morality, ethical principles, and a code of ethics. Morality refers to “personal values, character, or conduct of individuals within communities and societies.”[16] An ethical principle is a general guide, basic truth, or assumption that can be used with clinical judgment to determine a course of action. Four common ethical principles are beneficence (do good), nonmaleficence (do no harm), autonomy (control by the individual), and justice (fairness). A code of ethics is set for a profession and makes their primary obligations, values, and ideals explicit.
The American Nursing Association (ANA) guides nursing practice with the Code of Ethics for Nurses.[17] This code provides a framework for ethical nursing care and a guide for decision-making. The Code of Ethics for Nurses serves the following purposes:
- It is a succinct statement of the ethical values, obligations, duties, and professional ideals of nurses individually and collectively.
- It is the profession’s nonnegotiable ethical standard.
- It is an expression of nursing’s own understanding of its commitment to society.[18]
The ANA Code of Ethics contains nine provisions. See a brief description of each provision in the following box.
Provisions of the ANA Code of Ethics[19]
The nine provisions of the ANA Code of Ethics are briefly described below. The full code is available to read for free at Nursingworld.org.
Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
Provision 2: The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.
Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
Provision 4: The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.
Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
Provision 6: The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
Provision 7: The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.
The ANA Center for Ethics and Human Rights
In addition to publishing the Code of Ethics, the ANA Center for Ethics and Human Rights was established to help nurses navigate ethical and value conflicts and life-and-death decisions, many of which are common to everyday practice.
Check your knowledge with the following questions:
Learning Activities
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
Apply what you have learned from this chapter by completing the following learning activities:
1. You are a nursing student observing care in the Critical Care Unit (CCU) as part of your clinical course. You have been assisting a critical care nurse with the care of a client who has been experiencing significantly low blood pressures throughout the day. The nurse has to step away from the bedside to take a phone call and instructs you to increase the intravenous (IV) medication if the client's systolic blood pressure drops below 90 mmHg. What is the appropriate response to this instruction?
2. You are completing a clinical rotation on a medical-surgical unit and are invited to join a few staff nurses in the breakroom for a lunch break. While you are in the breakroom, you notice one of the staff nurses complaining loudly about a client and discussing sensitive client care information. What is an appropriate response to this situation?
Test your knowledge using this NCLEX Next Generation-style question. You may reset and resubmit your answers to this question an unlimited number of times.[20]
Test your knowledge using this NCLEX Next Generation-style question. You may reset and resubmit your answers to this question an unlimited number of times.[21]
Learning Activities
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
Practice what you have learned in this chapter by completing these learning activities. When accessing the online activities that contain videos, it is best to use Google Chrome or Firefox browsers.
1. To test your understanding of therapeutic and nontherapeutic terms, complete this online quiz:
Therapeutic Communication Techniques vs. Non-therapeutic Communication Techniques Quizlet
2. Consider the following scenario and describe actions that you might take to facilitate the communication experience.
You are caring for Mr. Curtis, an 87-year-old client newly admitted to the medical surgical floor with a hip fracture. You are preparing to complete his admission history and need to collect relevant health information and complete a physical exam. You approach the room, knock at the door, complete hand hygiene, and enter. Upon entry, you see Mr. Curtis is in bed surrounded by multiple family members. The television is on in the background, and you also note the sound of meal trays being delivered in the hallway.
Based on the described scenario, what actions might be implemented to aid in your communication with Mr. Curtis?
Test your knowledge using this NCLEX Next Generation-style question. You may reset and resubmit your answers to this question an unlimited number of times.[22]
Test your knowledge using this NCLEX Next Generation-style question. You may reset and resubmit your answers to this question an unlimited number of times.[23]
Prioritization
As new nurses begin their career, they look forward to caring for others, promoting health, and saving lives. However, when entering the health care environment, they often discover there are numerous and competing demands for their time and attention. Patient care is often interrupted by call lights, rounding physicians, and phone calls from the laboratory department or other interprofessional team members. Even individuals who are strategic and energized in their planning can feel frustrated as their task lists and planned patient-care activities build into a long collection of “to dos.”
Without utilization of appropriate prioritization strategies, nurses can experience time scarcity, a feeling of racing against a clock that is continually working against them. Functioning under the burden of time scarcity can cause feelings of frustration, inadequacy, and eventually burnout. Time scarcity can also impact patient safety, resulting in adverse events and increased mortality.[24] Additionally, missed or rushed nursing activities can negatively impact patient satisfaction scores that ultimately affect an institution's reimbursement levels.
It is vital for nurses to plan patient care and implement their task lists while ensuring that critical interventions are safely implemented first. Identifying priority patient problems and implementing priority interventions are skills that require ongoing cultivation as one gains experience in the practice environment.[25] To develop these skills, students must develop an understanding of organizing frameworks and prioritization processes for delineating care needs. These frameworks provide structure and guidance for meeting the multiple and ever-changing demands in the complex health care environment.
Let’s consider a clinical scenario in the following box to better understand the implications of prioritization and outcomes.
Scenario A
Imagine you are beginning your shift on a busy medical-surgical unit. You receive a handoff report on four medical-surgical patients from the night shift nurse:
- Patient A is a 34-year-old total knee replacement patient, post-op Day 1, who had an uneventful night. It is anticipated that she will be discharged today and needs patient education for self-care at home.
- Patient B is a 67-year-old male admitted with weakness, confusion, and a suspected urinary tract infection. He has been restless and attempting to get out of bed throughout the night. He has a bed alarm in place.
- Patient C is a 49-year-old male, post-op Day 1 for a total hip replacement. He has been frequently using his patient-controlled analgesia (PCA) pump and last rated his pain as a "6."
- Patient D is a 73-year-old male admitted for pneumonia. He has been hospitalized for three days and receiving intravenous (IV) antibiotics. His next dose is due in an hour. His oxygen requirements have decreased from 4 L/minute of oxygen by nasal cannula to 2 L/minute by nasal cannula.
Based on the handoff report you received, you ask the nursing assistant to check on Patient B while you do an initial assessment on Patient D. As you are assessing Patient D's oxygenation status, you receive a phone call from the laboratory department relating a critical lab value on Patient C, indicating his hemoglobin is low. The provider calls and orders a STAT blood transfusion for Patient C. Patient A rings the call light and states she and her husband have questions about her discharge and are ready to go home. The nursing assistant finds you and reports that Patient B got out of bed and experienced a fall during the handoff reports.
It is common for nurses to manage multiple and ever-changing tasks and activities like this scenario, illustrating the importance of self-organization and priority setting. This chapter will further discuss the tools nurses can use for prioritization.
Learning Objectives
- Prioritize nursing care based on patient acuity
- Use principles of time management to organize work
- Analyze effectiveness of time management strategies
- Use critical thinking to prioritize nursing care for patients
- Apply a framework for prioritization (e.g., Maslow, ABCs)
“So much to do, so little time.” This is a common mantra of today’s practicing nurse in various health care settings. Whether practicing in acute inpatient care, long-term care, clinics, home care, or other agencies, nurses may feel there is "not enough of them to go around.”
The health care system faces a significant challenge in balancing the ever-expanding task of meeting patient care needs with scarce nursing resources that has even worsened as a result of the COVID-19 pandemic. Many health care organizations have seen exacerbation in nurse turnover post-pandemic as nurses struggle with increasing stress, burnout, and feeling of uncertainty within the profession.[26] A recent nursing survey done by the American Nurses Foundation found that 60% of nurses reported extremely stressful, violent, and traumatic events as a result of the COVID-19 pandemic.[27] Additionally, a staggering 89% of nurses reported that their organizations experience significant staffing shortages.[28]
With a limited supply of registered nurses, nurse managers are often challenged to implement creative staffing practices such as sending staff to units where they do not normally work (i.e., floating), implementing mandatory staffing and/or overtime, utilizing travel nurses, or using other practices to meet patient care demands.[29] Staffing strategies can result in nurses experiencing increased patient assignments and workloads, extended shifts, or temporary suspension of paid time off. Nurses may receive a barrage of calls and text messages offering “extra shifts” and bonus pay, and although the extra pay may be welcomed, they often eventually feel burnt out trying to meet the ever-expanding demands of the patient-care environment.
A novice nurse who is still learning how to navigate the complex health care environment and provide optimal patient care may feel overwhelmed by these conditions. Novice nurses frequently report increased levels of stress and disillusionment as they transition to the reality of the nursing role.[30] How can we address this professional dilemma and enhance the novice nurse's successful role transition to practice? The novice nurse must enter the profession with purposeful tools and strategies to help prioritize tasks and manage time so they can confidently address patient care needs, balance role demands, and manage day-to-day nursing activities.
Let’s take a closer look at the foundational concepts related to prioritization and time management in the nursing profession.
Learning Objectives
- Prioritize nursing care based on patient acuity
- Use principles of time management to organize work
- Analyze effectiveness of time management strategies
- Use critical thinking to prioritize nursing care for patients
- Apply a framework for prioritization (e.g., Maslow, ABCs)
“So much to do, so little time.” This is a common mantra of today’s practicing nurse in various health care settings. Whether practicing in acute inpatient care, long-term care, clinics, home care, or other agencies, nurses may feel there is "not enough of them to go around.”
The health care system faces a significant challenge in balancing the ever-expanding task of meeting patient care needs with scarce nursing resources that has even worsened as a result of the COVID-19 pandemic. Many health care organizations have seen exacerbation in nurse turnover post-pandemic as nurses struggle with increasing stress, burnout, and feeling of uncertainty within the profession.[31] A recent nursing survey done by the American Nurses Foundation found that 60% of nurses reported extremely stressful, violent, and traumatic events as a result of the COVID-19 pandemic.[32] Additionally, a staggering 89% of nurses reported that their organizations experience significant staffing shortages.[33]
With a limited supply of registered nurses, nurse managers are often challenged to implement creative staffing practices such as sending staff to units where they do not normally work (i.e., floating), implementing mandatory staffing and/or overtime, utilizing travel nurses, or using other practices to meet patient care demands.[34] Staffing strategies can result in nurses experiencing increased patient assignments and workloads, extended shifts, or temporary suspension of paid time off. Nurses may receive a barrage of calls and text messages offering “extra shifts” and bonus pay, and although the extra pay may be welcomed, they often eventually feel burnt out trying to meet the ever-expanding demands of the patient-care environment.
A novice nurse who is still learning how to navigate the complex health care environment and provide optimal patient care may feel overwhelmed by these conditions. Novice nurses frequently report increased levels of stress and disillusionment as they transition to the reality of the nursing role.[35] How can we address this professional dilemma and enhance the novice nurse's successful role transition to practice? The novice nurse must enter the profession with purposeful tools and strategies to help prioritize tasks and manage time so they can confidently address patient care needs, balance role demands, and manage day-to-day nursing activities.
Let’s take a closer look at the foundational concepts related to prioritization and time management in the nursing profession.
This textbook discusses professional and management concepts related to the role of a registered nurse (RN) as defined by the American Nurses Association (ANA). The ANA publishes two resources that set standards and guide professional nursing practice in the United States: The Code of Ethics for Nurses With Interpretive Statements and Nursing: Scope and Standards of Practice. The Code of Ethics for Nurses With Interpretive Statements establishes an ethical framework for nursing practice across all roles, levels, and settings and is discussed in greater detail in the “Ethical Practice” chapter of this book. The Nursing: Scope and Standards of Practice resource defines the “who, what, where, when, why, and how of nursing” and sets the standards for practice that all registered nurses are expected to perform competently.[36]
The ANA defines the “who” of nursing practice as the nurses who have been educated, titled, and maintain active licensure to practice nursing. The “what” of nursing is the recently revised ANA definition of nursing: “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.”[37] Simply put, nurses treat human responses to health problems and life processes and advocate for the care of others.
Nursing practice occurs “when'' there is a need for nursing knowledge, wisdom, caring, leadership, practice, or education, anytime, anywhere. Nursing practice occurs in any environment “where'' there is a health care consumer in need of care, information, or advocacy. The “why” of nursing practice is described as nursing’s response to the changing needs of society to achieve positive health care consumer outcomes in keeping with nursing’s social contract and obligation to society. The “how” of nursing practice is defined as the ways, means, methods, and manners that nurses use to practice professionally.[38] The “how” of nursing, also referred to as a nurse’s “scope and standards of practice,” is further defined by each state’s Nurse Practice Act; agency policies, procedures, and protocols; and federal regulations and ANA’s Standards of Practice.
State Boards of Nursing and Nurse Practice Acts
RNs must legally follow regulations set by the Nurse Practice Act by the state in which they are caring for patients with their nursing license. The Board of Nursing is the state-specific licensing and regulatory body that sets standards for safe nursing care and issues nursing licenses to qualified candidates based on the Nurse Practice Act. The Nurse Practice Act is enacted by that state’s legislature and defines the scope of nursing practice and establishes regulations for nursing practice within that state. If nurses do not follow the standards and scope of practice set forth by the Nurse Practice Act, they may be disciplined by the Board of Nursing in the form of reprimand, probation, suspension, or revocation of their nursing license. Investigations and discipline actions are reportable among states participating in the Nurse Licensure Compact (that allows nurses to practice across state lines) or when a nurse applies for licensure in a different state. The scope and standards of practice set forth in the Nurse Practice Act can also be used as evidence if a nurse is sued for malpractice.
Find your state's Nurse Practice Act on the National Council of State Board of Nursing (NCSBN) website.
Read more about malpractice and protecting your nursing license in the “Legal Implications” chapter of this book.
Read Wisconsin’s Nurse Practice Act, Standards of Practice for Registered Nurses and Licensed Practical Nurses (Chapter N6) PDF, and Rules of Conduct (Chapter N7) PDF.
Agency Policies, Procedures, and Protocols
In addition to practicing according to the Nurse Practice Act in the state they are employed, nurses must also practice according to agency policies, procedures, and protocols.
A policy is an expected course of action set by an agency. For example, hospitals set a policy requiring a thorough skin assessment to be completed when a patient is admitted and then reassessed and documented daily.
Agencies also establish their own set of procedures. A procedure is the method or defined steps for completing a task. For example, each agency has specific procedural steps for inserting a urinary catheter.
A protocol is a detailed, written plan for performing a regimen of therapy. For example, agencies typically establish a hypoglycemia protocol that nurses can independently and quickly implement when a patient’s blood sugar falls below a specific number without first calling a provider. A hypoglycemia protocol typically includes actions such as providing orange juice and rechecking the blood sugar and then reporting the incident to the provider.
Agency-specific policies, procedures, and protocols supersede the information taught in nursing school, and nurses can be held legally liable if they don’t follow them. It is vital for nurses to review and follow current agency-specific procedures, policies, and protocols while also practicing according to that state's nursing scope of practice. Malpractice cases have occurred when a nurse was asked by their employer to do something outside their legal scope of practice, impacting their nursing license. It is up to you to protect your nursing license and follow the Nurse Practice Act when providing patient care. If you have a concern about an agency’s policy, procedure, or protocol, follow the agency’s chain of command to report your concern.
Federal Regulations
Nursing practice is impacted by regulations enacted by federal agencies. Two examples of federal agencies setting standards of care are The Joint Commission and the Centers for Medicare and Medicaid Services.
The Joint Commission accredits and certifies over 20,000 health care organizations in the United States. The Joint Commission’s standards help health care organizations measure, assess, and improve performance on functions that are essential to providing safe, high-quality care. The standards are updated regularly to reflect the rapid advances in health care and address topics such as patient rights and education, infection control, medication management, and prevention of medical errors. The annual National Patient Safety Goals are also set by The Joint Commission after reviewing emerging patient safety issues.[39]
The Centers for Medicare & Medicaid Services (CMS) is an example of another federal agency that establishes regulations affecting nursing care. CMS is a part of the U.S. Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid. The CMS establishes and enforces regulations to protect patient safety in hospitals that receive Medicare and Medicaid funding. For example, one CMS regulation often referred to as “checking the rights of medication administration” requires nurses to confirm specific information several times before medication is administered to a patient.[40]
Standards of Practice
The ANA defines Standards of Professional Nursing Practice as “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.”[41] These standards are classified into two categories: Standards of Practice and Standards of Professional Performance.
The ANA’s Standards of Practice describe a competent level of nursing practice as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation and forms the foundation of the nurse’s decision-making, practice, and provision of care.[42]
Read more information about the nursing process in the “Nursing Process” chapter of Open RN Nursing Fundamentals, 2e.[43]
The ANA’s Standards of Professional Performance “describe a competent level of behavior in the professional role, including activities related to ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship, and environmental health. All registered nurses are expected to engage in professional role activities, including leadership, reflective of their education, position, and role.”[44] This book discusses content related to these professional practice standards. Each professional practice standard is defined in the following sections with information provided to related content in this book and the Open RN Nursing Fundamentals, 2e textbook.[45]
Ethics
The ANA’s Ethics standard states, “The registered nurse integrates ethics in all aspects of practice.”[46]
Read about ethical nursing practice in the “Ethical Practice” chapter of this book.
Advocacy
The ANA’s Advocacy standard states, “The registered nurse demonstrates advocacy in all roles and settings.”[47]
Read about nurse advocacy in the “Advocacy” chapter of this book.
Respectful and Equitable Practice
The ANA’s Respectful and Equitable Practice standard states, “The registered nurse practices with cultural humility and inclusiveness.”
Read about cultural humility and culturally responsive care in the “Diverse Patients” chapter in Open RN Nursing Fundamentals, 2e.[48]
Communication
The ANA’s Communication standard states, “The registered nurse communicates effectively in all areas of professional practice.”[49]
Read about communicating with clients and team members in the “Communication” chapter in Open RN Nursing Fundamentals, 2e.[50]
Read about interprofessional communication strategies that promote patient safety in the “Collaboration Within the Interprofessional Team” chapter of this book.
Collaboration
The ANA’s Collaboration standard states, “The registered nurse collaborates with the health care consumer and other key stakeholders.”[51]
Read about strategies to enhance the performance of the interprofessional team and manage conflict in the “Collaboration Within the Interprofessional Team” chapter of this book.
Leadership
The ANA’s Leadership standard states, “The registered nurse leads within the profession and practice setting.”[52]
Read about leadership, management, and implementing change in the “Leadership and Management” chapter of this book.
Read about assigning, delegating, and supervising patient care in the “Delegation and Supervision” chapter of this book.
Read about tools for prioritizing patient care and managing resources for the nursing team in the “Prioritization” chapter of this book.
Education
The ANA’s Education standard states, “The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking.”[53]
Read about professional development and specialty certification in the “Preparation for the RN Role” chapter of this book.
Scholarly Inquiry
The ANA’s Scholarly Inquiry standard states, “The registered nurse integrates scholarship, evidence, and research findings into practice.”[54]
Read about integrating evidence-based practice into one’s nursing practice in the “Quality and Evidence-Based Practice” chapter of this book.
Quality of Practice
The ANA’s Quality of Practice standard states, “The nurse contributes to quality nursing practice.”[55]
Read about improving quality patient care and participating in quality improvement initiatives in the “Quality and Evidence-Based Practice” chapter of this book.
Professional Practice Evaluation
The ANA’s Professional Practice Evaluation standard states, “The registered nurse evaluates one’s own and others’ nursing practice.”[56]
Read about nursing practice within the legal framework of health care, negligence, malpractice, and protecting your nursing license in the “Legal Implications” chapter of this book.
Read about reviewing the interprofessional team’s performance, providing constructive feedback, and advocating for patient safety with assertive statements in the “Collaboration Within the Interprofessional Team” chapter of this book.
Resource Stewardship
The ANA’s Resource Stewardship standard states, “The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and used judiciously.”[57]
Read more about health care funding, reimbursement models, budgets and staffing, and resource stewardship in the “Health Care Economics” chapter of this book.
Environmental Health
The ANA’s Environmental Health standard states, “The registered nurse practices in a manner that advances environmental safety and health.”[58]
Read about promoting workplace safety for nurses in the “Safety” chapter in Open RN Nursing Fundamentals, 2e.[59]
Read about fostering a professional environment that does not tolerate abusive behaviors in the “Collaboration Within the Interprofessional Team” chapter of this book.
Read about addressing the impacts of social determinants of health in the “Advocacy” chapter of this book.
