8.5 Budgets and Staffing
Open Resources for Nursing (Open RN)
Economics and health care reimbursement models impact health care institutional budgets that ultimately impact nurse staffing. A budget is an estimate of revenue and expenses over a specified period of time, usually over a year. There are two basic types of health care budgets that affect nursing: capital and operating budgets. Capital budgets are used to plan investments and upgrades to tangible assets that lose or gain value over time. Capital is something that can be touched, such as buildings or computers. Operating budgets include personnel costs and annual facility operating costs.[1] Typically 40% of the operating budgets of health care agencies are dedicated to nursing staffing. As a result, nursing is often targeted for reduced hours and other cutbacks.[2]
What is the value of a nurse? Nurses are priceless to the clients, families, and communities they serve, but health care organizations are tasked with calculating the cost of delivering safe, high-quality nursing care using affordable staffing models. All members of the health care team must understand the relationship between economics, resources, budgeting, and staffing, and how these issues affect their ability to provide safe, quality care to their patients.
As health care agencies continue to adapt to meet “Pay for Performance” reimbursement models and deliver cost-effective care to an aging population with complex health needs, many nurses are experiencing changes in staffing models.[3] Strategies implemented by agencies to facilitate cost-effective nurse staffing include acuity-based staffing, team nursing, mandatory overtime, floating, on call, and off with benefits. Agencies may also use agency nurses when nurse shortages occur.
Acuity-Based Staffing
Historically, inpatient staffing patterns focused on “nurse-to-patient ratios” where a specific number of patients were assigned to each registered nurse during a shift. Acuity-based staffing is a patient assignment model that takes into account the level of patient care required based on the severity of a patient’s illness or condition. As a result of acuity-based staffing, the number of clients a nurse cares for often varies from shift to shift as the needs of the patients change. Acuity-based staffing promotes efficient use of resources by ensuring nurses have adequate time to care for complex patients.
Read more information about acuity-based staffing in the “Prioritization” chapter.
Team Nursing
Team nursing is a common staffing pattern that uses a combination of Registered Nurses (RNs), Licensed Practical/Vocational Nurses (LPN/VNs), and Assistive Personnel (AP) to care for a group of patients. The RN is the leader of a nursing team, making assignments and delegating nursing care to other members of the team with appropriate supervision. Team nursing is an example of allocating human resources wisely to provide quality and cost-effective care. In order for team nursing to be successful, team members must use effective communication and organize their shift as a team.
Read more about team nursing in the “Delegation and Supervision” chapter of this book.
Mandatory Overtime
When client numbers and acuity levels exceed the number of staff scheduled for a shift, nurses may experience mandatory overtime as an agency staffing tool. Mandatory overtime requires a nurse to stay and care for patients beyond their scheduled shift when there is a lack of nursing staff (often referred to as short staffing). The American Nurses Association recognizes mandatory overtime as a dangerous staffing practice because of patient safety concerns related to overtired staff. Depending on state laws, nurses can be held liable for patient abandonment or neglect charges for refusing to stay when mandated. Nurses should be aware of state and organizational policies related to mandatory overtime.[4]
Read more about ANA’s advocacy for adequate nurse staffing.
Floating
Floating is a common agency staffing strategy that asks nurses to temporarily work on a different unit to help cover a short-staffed shift. Floating can reduce personnel costs by reducing overtime payments for staff. It can also reduce nurse burnout occurring from working in an environment without enough personnel.
Nurses must be aware of their rights and responsibilities when asked to float because they are still held accountable for providing safe patient care according to their state’s Nurse Practice Act and professional standards of care. Before accepting a floating assignment, nurses should ensure the assignment is aligned with their skill set and they receive orientation to the new environment before caring for patients. If an error occurs and the nurse is held liable, the fact they received a floating assignment does not justify the error. As the ANA states, nurses don’t just have the right to refuse a floating patient assignment; they have the obligation to do so if it is unsafe.[5] The ANA has developed several questions to guide nurses through the decision process of accepting patient assignments. Review these questions in the following box.
ANA’s Suggested Questions When Deciding on Accepting a Patient Assignment[6]
- What is the assignment? Clarify what is expected; do not assume. Be certain about the details.
- What are the characteristics of the patients being assigned? Don’t just respond to the number of patients assigned. Make a critical assessment of the needs of each client and their complexity and stability. Be aware of the resources available to meet those needs.
- Do you have the expertise to care for the patients? Always ask yourself if you are familiar with caring for the types of patients assigned? If this is a “float assignment,” are you cross-trained to care for these patients? Is there a “buddy system” in place with staff who are familiar with the unit? If there is no cross-training or “buddy system,” has the patient load been modified accordingly?
- Do you have the experience and knowledge to manage the patients for whom you are being assigned care? If the answer to the question is “No,” you have an obligation to articulate your limitations. Limitations in experience and knowledge may not require refusal of the assignment, but rather an agreement regarding supervision or a modification of the assignment to ensure patient safety. If no accommodation for limitations is considered, the nurse has an obligation to refuse an assignment for which they lack education or experience.
- What is the geography of the assignment? Are you being asked to care for patients who are in close proximity for efficient management, or are the patients at opposite ends of the hall or in different units? If there are geographic difficulties, what resources are available to manage the situation? If the patients are in more than one unit and you must go to another unit to provide care, who will monitor patients out of your immediate attention?
- Is this a temporary assignment? When other staff are located for assistance, will you be relieved? If the assignment is temporary, it may be possible to accept a difficult assignment knowing that there will soon be reinforcements. Is there a pattern of short staffing at this agency, or is this truly an emergency?
- Is this a crisis or an ongoing staffing pattern? If the assignment is being made because of an immediate need or crisis in the unit, the decision to accept the assignment may be based on that immediate need. However, if the staffing pattern is an ongoing problem, you have the obligation to identify unmet standards of care that are occurring as a result of ongoing staffing inadequacies. This may result in a formal request for peer review using the appropriate channels.
- Can you take the assignment in good faith? If not, you will need to have the assignment modified or refuse the assignment. Consult your state’s Nurse Practice Act regarding clarification of accepting an assignment in good faith.
On Call and Off With Benefits
When staffing projected for a shift exceeds the number of clients admitted and their acuity, agencies often decrease staffing due to operating budget limitations. Two common approaches that agencies use to reduce staffing on a shift-to-shift basis are placing nurses “on call” or “off with benefits.”
On Call
On call is an agency staffing strategy when a nurse is not immediately needed for their scheduled shift. The nurse may have the options to report to work and do work-related education or stay home. When a nurse is on call, they typically receive a reduced hourly wage and have a required response time. A required response time means if a nurse who is on call is needed later in the shift, they need to be able to report and assume patient care in a designated amount of time.
Off With Benefits
A nurse may be placed “off with benefits” when not needed for their scheduled shift. When a nurse is placed off with benefits, they typically do not receive an hourly wage and are not expected to report to work or be on call, but still accrue benefits such as insurance and paid time off.
Agency Nursing
Agency nursing is an industry in health care that provides nurses to hospitals and health care facilities in need of staff. Nurse agencies employ nurses to work on an as-needed basis and place them in facilities that have staffing shortages.
Advocacy by the ANA for Appropriate Nurse Staffing
According to the ANA, there is significant evidence showing appropriate nurse staffing contributes to improved client outcomes and greater satisfaction for both clients and staff. Appropriate staffing levels have multiple client benefits, including the following[7]:
- Reduced mortality rates
- Reduced length of client stays
- Reduced number of preventable events, such as falls and infections
Nurses also benefit from appropriate staffing. Appropriate workload allows nurses to utilize their full expertise, without the pressure of fatigue. A recent report suggested that staff levels should depend on the following factors[8]:
- Patient complexity, acuity, or stability
- Number of admissions, discharges, and transfers
- Professional nurses’ and other staff members’ skill level and expertise
- Physical space and layout of the nursing unit
- Availability of technical support and other resources
Visit ANA’s interactive Principles of Nurse Staffing infographic.
Read more information about patient acuity tools in the “Prioritization” chapter.
Cost-Effective Nursing Care
One of ANA’s Standards of Professional Performance is Resource Stewardship. The 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.”[9] Nurses have a fiscal responsibility to demonstrate resource stewardship to the employing organization and payer of care. This responsibility extends beyond direct patient care and encompasses a broader role in health care sustainability. By effectively managing resources, nurses help reduce unnecessary expenditures and ensure that funds are allocated where they are most needed. This can include everything from minimizing waste in the use of medical supplies to optimizing staffing levels to avoid both overworking and underutilizing nursing staff.
Nurses can help contain health care costs by advocating for patients and ensuring their care is received on time, the plan of care is appropriate and individualized to them, and clear documentation has been completed. These steps reduce waste, avoid repeated tests, and ensure timely treatments that promote positive patient outcomes and reduce unnecessary spending. Nurses routinely incorporate these practices to provide cost-effective nursing care in their daily practice:
- Keeping supplies near the client’s room
- Preventing waste by only bringing needed supplies into a client’s room
- Avoiding prepackaged kits with unnecessary supplies
- Avoiding “Admission Bags” with unnecessary supplies
- Using financially-sound thinking
- Understanding health care costs and reimbursement models
- Charging out supplies and equipment according to agency policy
- Being Productive
- Organizing and prioritizing
- Using effective time management
- Grouping tasks when entering client rooms (i.e., clustering cares)
- Assigning and delegating nursing care to the nursing team according to the state Nurse Practice Act and agency policy
- Using effective team communication to avoid duplication of tasks and request assistance when needed
- Updating and individualizing clients’ nursing care plans according to their current needs
- Documenting for continuity of client care that avoids duplication and focuses on effective interventions based on identified outcomes and goals
- American Nurses Association. Advocacy. https://www.nursingworld.org/practice-policy/advocacy/ ↵
- Kenton, W. (2020, October 11). Capital budgeting. Investopedia. https://www.investopedia.com/terms/c/capitalbudgeting.asp ↵
- American Nurses Association. Advocacy. https://www.nursingworld.org/practice-policy/nurse-staffing/ ↵
- American Nurses Association. Nurse staffing. https://www.nursingworld.org/practice-policy/nurse-staffing/#staffinfo ↵
- American Nurses Association. Top issues for staff nurses. https://www.nursingworld.org/practice-policy/nurse-staffing/ ↵
- American Nurses Association. Top issues for staff nurses. https://www.nursingworld.org/practice-policy/nurse-staffing/ ↵
- American Nurses Association. Nurse staffing. https://www.nursingworld.org/practice-policy/nurse-staffing/ ↵
- American Nurses Association. Questions to ask in making the decision to accept a staffing assignment for nursing. https://www.nursingworld.org/practice-policy/nurse-staffing/questions-to-ask-in-making-the-decision-to-accept-a-staffing-assignment-for-nurses/ ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
Learning Objectives
- Distinguish among the different levels of nursing education
- Specify the ethical and legal boundaries of the student nurse as presented in the Code of Ethics and the Nurse Practice Act
- Detail responsibility for maintaining client confidentiality
- Describe the contribution of all members of the health care team
- Identify the role of evidence-based practice in nursing
- Identify the concept of quality in client care
- Discuss nursing scope of practice and standards of care
- Compare various settings in which nurses work
- Outline professional nursing organizations
Scope of practice refers to services a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their professional nursing license.[1] Nursing scope of practice provides a legal framework and structured guidance for activities that practical nurses and registered nurses can perform based on their nursing license. As a nursing student, and in the future as a nurse, it is always important to consider if you can perform a task you are requested to do based on your legal scope of practice - or are you putting your nursing education or nursing license at risk?
Nurses must also follow standards when providing nursing care. Standards are set by several organizations, including your state’s Nurse Practice Act, the American Nurses Association (ANA), agency policies and procedures, and federal regulators. These standards help guide nursing actions with the intent that safe, competent care is provided to the public.
This chapter will provide an overview of basic concepts related to nursing scope of practice and standards of care.
Brief History of Nursing
Before discussing scope and standards of nursing care, it is helpful to briefly review a history of the nursing profession. The nursing tradition began during the 5th and 6th centuries as a charitable means of caring for the sick, feeding and clothing the hungry and the poor, and offering care to widows and orphans. As such, nursing's earliest foundations were based on religious principles, with nuns often providing care. During the Middle Ages, medical and surgical treatments advanced, with formal training beginning for medical practitioners. Care of clients shifted from a religious perspective to a more medical perspective.[2]
In the mid-19th century, Florence Nightengale, answering a religious calling, was determined to enter the field of nursing, much to the chagrin of her family. At the time, nurses generally came from lower socioeconomic class families, and the focus of nursing was changing linens and performing other menial tasks in hospitals. Florence recognized a need for trained nurses, persisted in her calling, and ultimately helped lead nursing into a holistic, spiritual practice. Florence Nightingale is considered to be the founder of modern nursing practice.[3],[4] In 1860, Florence Nightengale established the first nursing school in the world and promoted the concept of nurses as a professional, educated workforce of caregivers for the sick.[5] See Figure 1.1[6] for a portrait of Florence Nightingale.
Florence Nightingale's contributions to health care started during the Crimean War in 1854. Her team discovered that poor health care for wounded soldiers was being delivered by overworked medical staff in a dirty environment. Florence documented the mortality rate in the hospital and created statistical models that demonstrated that 600 out of every 1,000 injured soldiers died because of preventable communicable and infectious diseases. This statistical analysis was the early foundation of evidence-based practice that nurses use today. Florence’s nursing interventions were simple and focused on providing a clean environment, clean water, and good nutrition to promote healing. For example, she provided fruit as part of the care for the wounded soldiers to promote good nutrition and healing. With these simple actions, the mortality rate of the soldiers decreased from 60% to 2.2%.[7]
In 1859, Nightingale wrote a book titled Notes on Nursing that served as the cornerstone of the Nightingale School of Nursing curriculum. Nightingale believed in the importance of placing a patient in an environment that promoted healing where they could recover from disease. She promoted this knowledge as distinct from medical knowledge. Her emphasis on the value of the environment formed many of the foundational principles that are still used to promote healing in health care settings today. She also insisted on the importance of building trusting relationships with patients and believed in the therapeutic healing that resulted from nurses’ presence with patients. She promoted the concept of confidentiality, stating a nurse “should never answer questions about her sick except to those who have a right to ask them.”[8] These nursing concepts formed the foundation of nursing practice as we know it today.
Modern nursing has reinvented itself a number of times as health care has advanced and changed over the past 160 years. With more than four million members, the nursing profession represents the largest segment of the United States’ health care workforce. Nursing practice covers a broad continuum, including health promotion, disease prevention, coordination of care, and palliative care when cure is not possible. Nurses directly affect client care and provide the majority of client assessments, evaluations, and care in hospitals, nursing homes, clinics, schools, workplaces, and ambulatory settings. They are at the front lines in ensuring that client care is delivered safely, effectively, and compassionately. Additionally, nurses attend to patients and their families in a holistic way that often goes beyond physical health needs and recognize social, mental, emotional, and spiritual needs.[9]
Standards for nursing care are set by several organizations, including state Nurse Practice Acts, the American Nurses Association (ANA), agency policies and procedures, federal regulators, and other professional nursing organizations. These standards promote guidelines for safe, competent care to be provided to the public.
Nurse Practice Act
Nurses must legally follow regulations set by the Nurse Practice Act (NPA) in the state in which they work. The Nurse Practice Act is enacted by that state's legislature, defines the scope of practice for nurses in that state, and establishes regulations for nursing practice. If nurses do not follow the standards and scope of practice set forth by the Nurse Practice Act, they can have their nursing license revoked by the state Board of Nursing. The Board of Nursing is a licensing and regulatory body that issues nursing licenses to qualified candidates and also provides discipline for nurses who do not follow standards and scope of practice established in the Nurse Practice Act.
Each state has their own Nurse Practice Act. To read more about the the Wisconsin Board of Nursing, Standards of Practice, and Rules of Conduct, use the information provided below.[10]
Read more details about the Wisconsin Administrative Code and the Board of Nursing.
Read about Wisconsin Standards of Practice for Nurses in Chapter N 6.
Read about Wisconsin Rules of Conduct in Chapter N 7.
Nursing students must understand their scope of practice as outlined in the Nurse Practice Act in the state in which they are completing their clinical courses. Nursing students are legally accountable for the quality of care they provide to clients just as nurses are accountable. Students are expected to recognize the limits of their knowledge and experience and appropriately alert faculty or other authority figures regarding situations that are beyond their competency. A violation of the standards of practice constitutes unprofessional conduct and can result in the Board of Nursing denying a license to a nursing graduate.
American Nurses Association (ANA)
The American Nurses Association (ANA) is a national, professional nursing organization that was established in 1896. The ANA represents the interests of nurses in all 50 states of America while also promoting improved health care for everyone. The mission of the ANA is to “lead the profession to shape the future of nursing and health care.”[11] The ANA states that it exists to advance the nursing profession by doing the following:
- Fostering high standards of nursing practice
- Promoting a safe and ethical work environment
- Bolstering the health and wellness of nurses
- Advocating on health care issues that affect nurses and the public[12]
Read more information about the American Nurses Association.
View the Discover the American Nurses Association video.[13]
ANA Scope and Standards of Practice
The American Nurses Association (ANA) publishes two resources that set standards and guide professional nursing practice in the United States: The Code of Ethics for Nurses and Nursing: Scope and Standards of Practice. The Code of Ethics for Nurses establishes an ethical framework for nursing practice across all roles, levels, and settings. It is discussed in greater detail in the “Legal and Ethical Considerations” section of this chapter. The Nursing: Scope and Standards of Practice describes a professional nurse's scope of practice and defines the who, what, where, when, why, and how of nursing. It also sets 18 standards of professional practice that all registered nurses are expected to perform competently.[14]
The “who” of nursing practice are the nurses who have been educated, titled, and maintain active licensure to practice nursing. The “what” of nursing is the recently revised 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.”[15] 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.[16] The “how” of nursing is further defined by the standards of practice set by the ANA. There are two sets of standards, the Standards of Professional Nursing Practice and the Standards of Professional Performance.
The ANA Standards of Professional Nursing Practice are "authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently."[17] These standards define a competent level of nursing practice based on the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.[18] Each of these standards is further discussed in the “Nursing Process” chapter of this book.
The ANA Standards of Professional Performance are 12 additional standards that describe a nurse's professional behavior, 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 these professional role activities based on their level of education, position, and role. Registered nurses are accountable for their professional behaviors to themselves, health care consumers, peers, and ultimately to society.[19] The 2021 Standards of Professional Performance are as follows:
- Ethics. The registered nurse integrates ethics in all aspects of practice.
- Advocacy. The registered nurse demonstrates advocacy in all roles and settings.
- Respectful and Equitable Practice. The registered nurse practices with cultural humility and inclusiveness.
- Communication. The registered nurse communicates effectively in all areas of professional practice.
- Collaboration. The registered nurse collaborates with the health care consumer and other key stakeholders.
- Leadership. The registered nurse leads within the profession and practice setting.
- Education. The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking.
- Scholarly Inquiry. The registered nurse integrates scholarship, evidence, and research findings into practice.
- Quality of Practice. The registered nurse contributes to quality nursing practice.
- Professional Practice Evaluation. The registered nurse evaluates one’s own and others’ nursing practice.
- Resource Stewardship. The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and judiciously used.
- Environmental Health. The registered nurse practices in a manner that advances environmental safety and health.[20]
Years ago, nurses were required to recite the Nightingale pledge to publicly confirm their commitment to maintain the profession’s high ethical and moral values: “I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and family affairs coming to my knowledge in the practice of my calling, with loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.” Although some of the words are outdated, the meaning is clear: Nursing is a calling, not just a job; to answer that call, nurses must be dedicated to serve their community according to the ANA standards of care and code of ethics.[21]
Employer Policies, Procedures, and Protocols
In addition to professional nursing standards set by the American Nurses Association and the state Nurse Practice Act where they work, nurses and nursing students must also practice according to agency policies, procedures, and protocols. For example, hospitals often set a policy that requires a thorough skin assessment must be completed and documented daily on every client. If a nurse did not follow this policy and a client developed a pressure injury, the nurse could be held liable. In addition, every agency has their own set of procedures and protocols that a nurse and nursing student must follow. For example, each agency has specific procedural steps for performing nursing skills, such as inserting urinary catheters. A protocol is defined by the Wisconsin Nurse Practice Act as a “precise and detailed written plan for a regimen of therapy.” For example, agencies typically have a hypoglycemia protocol that nurses automatically implement when a client’s blood sugar falls below a specific number. The hypoglycemia protocol includes actions such as providing orange juice and rechecking the blood sugar. These agency-specific policies, procedures, and protocols supersede the information taught in nursing school, and nurses and nursing students can be held legally liable if they don’t follow them. Therefore, it is vital for nurses and nursing students to always review and follow current agency-specific procedures, policies, and protocols when providing client care.
Nurses and nursing students must continue to follow their scope of practice as defined by the Nurse Practice Act in the state they are practicing when following agency policies, procedures, and protocols. Situations have occurred when a nurse or nursing student was asked by an agency to do something outside their defined scope of practice that impaired their nursing license. It is always up to you to protect your nursing license and follow the state’s Nurse Practice Act when providing client care.
Federal Regulations
In addition to nursing scope of practice and standards being defined by state Nurse Practice Acts, the American Nurses Association, and employer policies, procedures, and protocols, nursing practice is also influenced by federal regulations enacted by agencies such as The Joint Commission and the Centers for Medicare and Medicaid.
The Joint Commission
The Joint Commission is a national organization that accredits and certifies over 20,000 health care organizations in the United States. The mission of The Joint Commission (TJC) is to continuously improve health care for the public by inspiring health care organizations to excel in providing safe and effective care of the highest quality and value.[22] The Joint Commission sets standards for providing safe, high-quality health care. Examples of standards include following National Patient Safety Goals and establishing a Safety Culture in health care agencies.
National Patient Safety Goals
The Joint Commission establishes annual National Patient Safety Goals for various types of agencies based on data regarding current national safety concerns.[23] For example, National Patient Safety Goals for hospitals include the following:
- Identify Patients Correctly
- Improve Staff Communication
- Use Medicines Safely
- Use Alarms Safely
- Prevent Infection
- Identify Patient Safety Risks
- Prevent Mistakes in Surgery
Nurses, nursing students, and other staff members are expected to incorporate actions related to these safety goals into their daily client care. For example, SBAR (Situation, Background, Assessment, and Recommendation) handoff reporting techniques, barcode scanning equipment, and perioperative team “time-outs” prior to surgery are examples of actions incorporated at agencies based on National Patient Safety Goals. Nursing programs also use National Patient Safety Goals to guide their curriculum and clinical practice expectations. National Patient Safety Goals are further discussed in the “Safety” chapter of this book.
Use the information provided below to read more about The Joint Commission and National Patient Safety Goals.
Safety Culture
A safety culture empowers nurses, nursing students, and other staff members to speak up about their concerns about client risks and to report errors and near misses, all of which drive improvement in client care and reduce the incidences of client harm.[24] Many health care agencies have implemented a safety culture in their workplace and successfully reduced incidences of client harm. An example of a safety culture action is a nurse or nursing student creating an incident report when an error occurs when administering medication. The incident report is used by the agency to investigate system factors that contribute to errors. To read more about how The Joint Commission encourages agencies create a safety culture, use the information provided in the following box.
Read more about Safety Culture from The Joint Commission.
Reimbursement for Health Services and Regulations
Although many individuals pursue nursing careers to help others, it is important to realize that health care is a business. Even non-profit organizations rely on funding to provide services, pay employees, and maintain the facility and equipment. There are several sources of funding for health care, including private health insurance or government-funded programs like Medicare and Medicaid. No matter what type of funding source, agencies must comply with state and federal regulations.
Private Health Insurance
The health insurance industry provides private health insurance that is sponsored by employers or purchased privately by individuals from the Health Insurance Marketplace. Private insurance programs must comply with state and federal regulations even though they are privately owned. Read more about the Affordable Care Act in the following box.
Affordable Care Act
The Affordable Care Act (ACA) of 2010, commonly referred to as "Obamacare," created cost-reduction programs for private insurance through a public insurance marketplace. Insurance premiums are subsidized by taxpayer funds to help reduce the cost of health insurance and make it more affordable. Subsidies are provided for incomes between 100% and 400% of the federal poverty level. For example, in 2023, the income range for a family of four was $30,000 to $120,000.[25] These subsidies have significantly decreased the number of uninsured individuals, but unfortunately, insurance premiums sold through the marketplace can still be high. Approximately 7.7% of individuals and families in the United States remain uninsured, resulting in increased health risks due to lack of participation in preventive services, well child care, dental care, and treatment of chronic disease. As a result, visits to the Emergency Room often increase when clients delay care due to cost concerns, further contributing to the cost of health care as hospitals are often not reimbursed for these visits.[26],[27]
Federal and State-Funded Health Care
Medicare is federally funded health care coverage of individuals aged 65 or older, individuals younger than 65 with certain disabilities, or those at any age with end-stage renal disease. Medicaid is a combination of state and federally funded health care coverage of low-income adults, pregnant women, and children. Agencies receiving Medicare or Medicaid reimbursement must comply with state and federal regulations and meet established client outcomes, or their reimbursement rates are decreased or eliminated. Read more about Medicare in the following box.
Medicare
Medicare uses a system of reimbursement based on diagnosis-related groups (DRGs). DRGs classify clients with similar clinical characteristics, such as age, gender, severity of disease, and comorbidities, with the rationale that these clients have similar care needs. Based on these DRGs, reimbursement occurs at rates set by the Centers for Medicare & Medicaid Services (CMS) for qualifying services. Differences between set reimbursement rates and health care organization charges cannot be passed on to the individual, although the individuals may be required to pay copays for care received. By agreeing to accept clients with Medicare or Medicaid coverage, the health care organization agrees to accept these rates of reimbursement, although they may be less than the actual cost of providing care. For example, in 2017, Medicaid reimbursement was 89% of the cost of providing care.[28],[29],[30]
Centers for Medicare & Medicaid Services
The Centers for Medicare & Medicaid Services (CMS) is a federal agency that establishes and enforces regulations to protect client safety in hospitals that receive Medicare and Medicaid funding. For example, one CMS regulation states that a hospital’s policies and procedures must require confirmation of specific information before medication is administered to clients. This CMS regulation is often referred to as "checking the rights of medication administration." You can read more information about checking the rights of medication administration in the "Administration of Enteral Medications" chapter of the Open RN Nursing Skills, 2e textbook.[31]
CMS also enforces quality standards in health care organizations that receive Medicare and Medicaid funding. These organizations are reimbursed based on the quality of their client outcomes. For example, organizations with high rates of healthcare-associated infections (HAI) receive less reimbursement for services they provide. As a result, many agencies have reexamined their policies, procedures, and protocols to promote optimal client outcomes and maximum reimbursement.
Now that we have discussed various agencies that affect a nurse’s scope and standards of practice, let’s review various types of health care settings where nurses work and members of the health care team.
Standards for nursing care are set by several organizations, including state Nurse Practice Acts, the American Nurses Association (ANA), agency policies and procedures, federal regulators, and other professional nursing organizations. These standards promote guidelines for safe, competent care to be provided to the public.
Nurse Practice Act
Nurses must legally follow regulations set by the Nurse Practice Act (NPA) in the state in which they work. The Nurse Practice Act is enacted by that state's legislature, defines the scope of practice for nurses in that state, and establishes regulations for nursing practice. If nurses do not follow the standards and scope of practice set forth by the Nurse Practice Act, they can have their nursing license revoked by the state Board of Nursing. The Board of Nursing is a licensing and regulatory body that issues nursing licenses to qualified candidates and also provides discipline for nurses who do not follow standards and scope of practice established in the Nurse Practice Act.
Nursing students must understand their scope of practice as outlined in the Nurse Practice Act in the state in which they are completing their clinical courses. Nursing students are legally accountable for the quality of care they provide to clients just as nurses are accountable. Students are expected to recognize the limits of their knowledge and experience and appropriately alert faculty or other authority figures regarding situations that are beyond their competency. A violation of the standards of practice constitutes unprofessional conduct and can result in the Board of Nursing denying a license to a nursing graduate.
American Nurses Association (ANA)
The American Nurses Association (ANA) is a national, professional nursing organization that was established in 1896. The ANA represents the interests of nurses in all 50 states of America while also promoting improved health care for everyone. The mission of the ANA is to “lead the profession to shape the future of nursing and health care.”[32] The ANA states that it exists to advance the nursing profession by doing the following:
- Fostering high standards of nursing practice
- Promoting a safe and ethical work environment
- Bolstering the health and wellness of nurses
- Advocating on health care issues that affect nurses and the public[33]
Read more information about the American Nurses Association.
View the Discover the American Nurses Association video.[34]
ANA Scope and Standards of Practice
The American Nurses Association (ANA) publishes two resources that set standards and guide professional nursing practice in the United States: The Code of Ethics for Nurses and Nursing: Scope and Standards of Practice. The Code of Ethics for Nurses establishes an ethical framework for nursing practice across all roles, levels, and settings. It is discussed in greater detail in the “Legal and Ethical Considerations” section of this chapter. The Nursing: Scope and Standards of Practice describes a professional nurse's scope of practice and defines the who, what, where, when, why, and how of nursing. It also sets 18 standards of professional practice that all registered nurses are expected to perform competently.[35]
The “who” of nursing practice are the nurses who have been educated, titled, and maintain active licensure to practice nursing. The “what” of nursing is the recently revised 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.”[36] 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.[37] The “how” of nursing is further defined by the standards of practice set by the ANA. There are two sets of standards, the Standards of Professional Nursing Practice and the Standards of Professional Performance.
The ANA Standards of Professional Nursing Practice are "authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently."[38] These standards define a competent level of nursing practice based on the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.[39] Each of these standards is further discussed in the “Nursing Process” chapter of this book.
The ANA Standards of Professional Performance are 12 additional standards that describe a nurse's professional behavior, 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 these professional role activities based on their level of education, position, and role. Registered nurses are accountable for their professional behaviors to themselves, health care consumers, peers, and ultimately to society.[40] The 2021 Standards of Professional Performance are as follows:
- Ethics. The registered nurse integrates ethics in all aspects of practice.
- Advocacy. The registered nurse demonstrates advocacy in all roles and settings.
- Respectful and Equitable Practice. The registered nurse practices with cultural humility and inclusiveness.
- Communication. The registered nurse communicates effectively in all areas of professional practice.
- Collaboration. The registered nurse collaborates with the health care consumer and other key stakeholders.
- Leadership. The registered nurse leads within the profession and practice setting.
- Education. The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking.
- Scholarly Inquiry. The registered nurse integrates scholarship, evidence, and research findings into practice.
- Quality of Practice. The registered nurse contributes to quality nursing practice.
- Professional Practice Evaluation. The registered nurse evaluates one’s own and others’ nursing practice.
- Resource Stewardship. The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and judiciously used.
- Environmental Health. The registered nurse practices in a manner that advances environmental safety and health.[41]
Years ago, nurses were required to recite the Nightingale pledge to publicly confirm their commitment to maintain the profession’s high ethical and moral values: “I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and family affairs coming to my knowledge in the practice of my calling, with loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.” Although some of the words are outdated, the meaning is clear: Nursing is a calling, not just a job; to answer that call, nurses must be dedicated to serve their community according to the ANA standards of care and code of ethics.[42]
Employer Policies, Procedures, and Protocols
In addition to professional nursing standards set by the American Nurses Association and the state Nurse Practice Act where they work, nurses and nursing students must also practice according to agency policies, procedures, and protocols. For example, hospitals often set a policy that requires a thorough skin assessment must be completed and documented daily on every client. If a nurse did not follow this policy and a client developed a pressure injury, the nurse could be held liable. In addition, every agency has their own set of procedures and protocols that a nurse and nursing student must follow. For example, each agency has specific procedural steps for performing nursing skills, such as inserting urinary catheters. A protocol is defined by the Wisconsin Nurse Practice Act as a “precise and detailed written plan for a regimen of therapy.” For example, agencies typically have a hypoglycemia protocol that nurses automatically implement when a client’s blood sugar falls below a specific number. The hypoglycemia protocol includes actions such as providing orange juice and rechecking the blood sugar. These agency-specific policies, procedures, and protocols supersede the information taught in nursing school, and nurses and nursing students can be held legally liable if they don’t follow them. Therefore, it is vital for nurses and nursing students to always review and follow current agency-specific procedures, policies, and protocols when providing client care.
Nurses and nursing students must continue to follow their scope of practice as defined by the Nurse Practice Act in the state they are practicing when following agency policies, procedures, and protocols. Situations have occurred when a nurse or nursing student was asked by an agency to do something outside their defined scope of practice that impaired their nursing license. It is always up to you to protect your nursing license and follow the state’s Nurse Practice Act when providing client care.
Federal Regulations
In addition to nursing scope of practice and standards being defined by state Nurse Practice Acts, the American Nurses Association, and employer policies, procedures, and protocols, nursing practice is also influenced by federal regulations enacted by agencies such as The Joint Commission and the Centers for Medicare and Medicaid.
The Joint Commission
The Joint Commission is a national organization that accredits and certifies over 20,000 health care organizations in the United States. The mission of The Joint Commission (TJC) is to continuously improve health care for the public by inspiring health care organizations to excel in providing safe and effective care of the highest quality and value.[43] The Joint Commission sets standards for providing safe, high-quality health care. Examples of standards include following National Patient Safety Goals and establishing a Safety Culture in health care agencies.
National Patient Safety Goals
The Joint Commission establishes annual National Patient Safety Goals for various types of agencies based on data regarding current national safety concerns.[44] For example, National Patient Safety Goals for hospitals include the following:
- Identify Patients Correctly
- Improve Staff Communication
- Use Medicines Safely
- Use Alarms Safely
- Prevent Infection
- Identify Patient Safety Risks
- Prevent Mistakes in Surgery
Nurses, nursing students, and other staff members are expected to incorporate actions related to these safety goals into their daily client care. For example, SBAR (Situation, Background, Assessment, and Recommendation) handoff reporting techniques, barcode scanning equipment, and perioperative team “time-outs” prior to surgery are examples of actions incorporated at agencies based on National Patient Safety Goals. Nursing programs also use National Patient Safety Goals to guide their curriculum and clinical practice expectations. National Patient Safety Goals are further discussed in the “Safety” chapter of this book.
Use the information provided below to read more about The Joint Commission and National Patient Safety Goals.
Safety Culture
A safety culture empowers nurses, nursing students, and other staff members to speak up about their concerns about client risks and to report errors and near misses, all of which drive improvement in client care and reduce the incidences of client harm.[45] Many health care agencies have implemented a safety culture in their workplace and successfully reduced incidences of client harm. An example of a safety culture action is a nurse or nursing student creating an incident report when an error occurs when administering medication. The incident report is used by the agency to investigate system factors that contribute to errors. To read more about how The Joint Commission encourages agencies create a safety culture, use the information provided in the following box.
Read more about Safety Culture from The Joint Commission.
Reimbursement for Health Services and Regulations
Although many individuals pursue nursing careers to help others, it is important to realize that health care is a business. Even non-profit organizations rely on funding to provide services, pay employees, and maintain the facility and equipment. There are several sources of funding for health care, including private health insurance or government-funded programs like Medicare and Medicaid. No matter what type of funding source, agencies must comply with state and federal regulations.
Private Health Insurance
The health insurance industry provides private health insurance that is sponsored by employers or purchased privately by individuals from the Health Insurance Marketplace. Private insurance programs must comply with state and federal regulations even though they are privately owned. Read more about the Affordable Care Act in the following box.
Affordable Care Act
The Affordable Care Act (ACA) of 2010, commonly referred to as "Obamacare," created cost-reduction programs for private insurance through a public insurance marketplace. Insurance premiums are subsidized by taxpayer funds to help reduce the cost of health insurance and make it more affordable. Subsidies are provided for incomes between 100% and 400% of the federal poverty level. For example, in 2023, the income range for a family of four was $30,000 to $120,000.[46] These subsidies have significantly decreased the number of uninsured individuals, but unfortunately, insurance premiums sold through the marketplace can still be high. Approximately 7.7% of individuals and families in the United States remain uninsured, resulting in increased health risks due to lack of participation in preventive services, well child care, dental care, and treatment of chronic disease. As a result, visits to the Emergency Room often increase when clients delay care due to cost concerns, further contributing to the cost of health care as hospitals are often not reimbursed for these visits.[47],[48]
Federal and State-Funded Health Care
Medicare is federally funded health care coverage of individuals aged 65 or older, individuals younger than 65 with certain disabilities, or those at any age with end-stage renal disease. Medicaid is a combination of state and federally funded health care coverage of low-income adults, pregnant women, and children. Agencies receiving Medicare or Medicaid reimbursement must comply with state and federal regulations and meet established client outcomes, or their reimbursement rates are decreased or eliminated. Read more about Medicare in the following box.
Medicare
Medicare uses a system of reimbursement based on diagnosis-related groups (DRGs). DRGs classify clients with similar clinical characteristics, such as age, gender, severity of disease, and comorbidities, with the rationale that these clients have similar care needs. Based on these DRGs, reimbursement occurs at rates set by the Centers for Medicare & Medicaid Services (CMS) for qualifying services. Differences between set reimbursement rates and health care organization charges cannot be passed on to the individual, although the individuals may be required to pay copays for care received. By agreeing to accept clients with Medicare or Medicaid coverage, the health care organization agrees to accept these rates of reimbursement, although they may be less than the actual cost of providing care. For example, in 2017, Medicaid reimbursement was 89% of the cost of providing care.[49],[50],[51]
Centers for Medicare & Medicaid Services
The Centers for Medicare & Medicaid Services (CMS) is a federal agency that establishes and enforces regulations to protect client safety in hospitals that receive Medicare and Medicaid funding. For example, one CMS regulation states that a hospital’s policies and procedures must require confirmation of specific information before medication is administered to clients. This CMS regulation is often referred to as "checking the rights of medication administration." You can read more information about checking the rights of medication administration in the "Administration of Enteral Medications" chapter of the Open RN Nursing Skills, 2e textbook.[52]
CMS also enforces quality standards in health care organizations that receive Medicare and Medicaid funding. These organizations are reimbursed based on the quality of their client outcomes. For example, organizations with high rates of healthcare-associated infections (HAI) receive less reimbursement for services they provide. As a result, many agencies have reexamined their policies, procedures, and protocols to promote optimal client outcomes and maximum reimbursement.
Now that we have discussed various agencies that affect a nurse’s scope and standards of practice, let’s review various types of health care settings where nurses work and members of the health care team.
