Specialty Nursing Scope and Standards of Practice: Incorporating Content about the Care of Older Adults
Article Outline
- Overview
- Development of Specialty Association Scope and Standards
- Consultation to Specialty Associations to Incorporate Language about Care of Older Adults into Scope and Standards of Practice
- Successful Inclusion of Geriatric Content into Newly Created and Revised Scope and Standards
- Case Example: The American Holistic Nurses Association (AHNA)
- Case Example: The Cardiovascular Nursing Task Force
- Case Example: the Hospice and Palliative Nurses Association (HPNA)
- Conclusion
- References
- Biography
- Copyright
Overview
According to the American Nurses Association (ANA), the scope of practice statement and standards of practice for the nursing profession describe “what nursing is, what nurses do, and those responsibilities for which nurses are accountable.”1 Similarly, the more detailed specialty nursing scope statement and standards of practice can deeply influence nursing practice in each specialty. Specialty scope and standards of practice describe the knowledge, skills, and abilities that hospitals and other health care agencies can expect from the nurses they hire. They influence the development of continuing-education programs, are directly tied to the contents of specialty certification examinations, and guide the development of curricula that nurses are taught in specialty master’s programs. Agencies that employ nurses rely on the scope and standards of practice when creating job descriptions and establishing baseline competencies.
Although older adults make up the majority of patients in many nursing specialties, until recently, the scope and standards documents for specialty nursing practice rarely addressed issues related to older adults, and, in fact, many simply did not mention the age of the patient as influencing practice. In September 2005, the ANA included formal language addressing care of older adults in its document Recognition of a Nursing Specialty, Approval of a Specialty Nursing Scope of Practice Statement and Acknowledgement of Specialty Nursing Standards of Practice, which was approved by the ANA Congress on Nursing Practice and Economics. All new or revised specialty nursing scopes and standards of practice that are submitted to the 2-step review process through the ANA Congress on Nursing Practice and Economics would address care issues related to older adults and, where applicable, identify “…that older adults represent either the primary or predominant population served, or a unique population served by the specialty.”1
This ANA resource includes examples of how specialty associations might infuse their scope and standards documents with language reflecting quality care of older adults. Defining the need to include gerontology-specific content in these scope and standards documents was a pivotal step for the ANA, which reviews many of these documents and whose goal is to “develop and disseminate the cornerstone work of ANA, such as standards… to the public and the profession” (www.nursingworld.org). ANA’s focus on gerontology in the scope and standards process conveyed that it was important for specialty associations to commit themselves to the elderly, because nearly all nurses care for older patients.
Many of the 55 specialty associations participating in the Nurse Competence in Aging (NCA) project (see article Ensuring Competence of Specialty Nurses in Care of Older Adults on pages 9-14 for a full description of NCA) were receptive to the new ANA recommendation. For those that had built up strong momentum toward improving knowledge of older-adult care through their work in the NCA project, a revision of their scope and standards document was an important next step.
The timing of the ANA’s statement dovetailed well with other efforts of the NCA project to reach out to specialty nurses through their associations. In this article, we review the overall purpose for specialty associations to develop scope of practice statements and standards of specialty nursing practice and identify the consultation provided to specialty associations to incorporate language about care of older adults into their scope and standards documents. We present case examples of successful inclusion of geriatric-specific content by the:
Development of Specialty Association Scope and Standards
In 1973, the ANA, the professional organization that represents practicing nurses, first published Standards for Nursing Practice.2 As part of these standards, the ANA identified assessment, interventions, and outcomes as the basic elements that constitute nursing practice. Subsequent publications by the ANA, beginning in 1974 with the Standards of Medical-Surgical Nursing Practice and continuing through the most recent Hospice and Palliative Nursing: Scope and Standards of Practice (2007), continue to provide the framework by which to measure the quality of nursing practice in clinical practice specialties.
The associations that represent the various nursing specialties have a responsibility to establish a scope of practice statement and set standards that describe their distinct focus of practice, and, through certification, to ensure that nurses within the specialty are held to high and consistent standards of knowledge and skills. Historically, associations have produced a scope statement about the full range of practice within the specialty and standards of practice describing specific types of knowledge and skills required without categorization such as age, gender, race, or any single patient type.
Whether an association works with the ANA or independently, the process for establishing a scope of practice statement and standards of practice is rigorous and time-consuming. The ANA suggests that when specialty associations develop new standards or revise existing standards (the ANA recommends that this occur at least every 5 years), they use the Nursing: Scope and Standards of Practice3 as a template to describe the complexity of their practice. That document identifies 6 standards of practice (assessment, diagnosis, outcomes identification, planning, implementation, and evaluation) and 9 standards of professional performance (quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, resource utilization, and leadership).
Associations typically establish workgroups or task forces to create new documents or revise existing ones and then submit that work to the ANA’s Committee on Nursing Practice Standards and Guidelines. This committee reviews the submission against criteria approved by the ANA Congress on Nursing Practice and Economics. During the second review phase, the Congress on Nursing Practice and Economics conducts its own examination and determination for approval of the specialty scope of practice statement and acknowledgment of specialty nursing standards of practice.
Beginning in 2005, the ANA included language as to the incorporation of gerontology-specific content in the materials they sent to specialty associations that were creating or revising their scope and standards of practice.1 The ANA document addresses an association’s desire to identify the growing number of older adults cared for by nurses within that specialty. It provides examples of how, in the scope and standards documents, a specialty can recognize care of older adults; for example:
Consultation to Specialty Associations to Incorporate Language about Care of Older Adults into Scope and Standards of Practice
The NCA project provides consultation to encourage specialty associations to incorporate language about care of older adults when creating or revising their scope and standards documents. As a first step, The Hartford Institute for Geriatric Nursing prepared a guideline document, “Professional Nursing Associations Creating &/or Revising Professional Scope and Standards: Guidelines for Addressing Issues Related to Care of Older Adults,” which addresses scope and standards of practice generally and, where applicable, for advanced practice registered nurses (APRNs). The guidelines are based on a comprehensive review of specialty association scope and standards documents and input from an expert review panel made up of specialty association members and geriatric experts. The guidelines provide draft language for a specialty association to consider in both the 6 standards of practice and 9 standards of professional performance.
Through a listserv, all specialty associations participating in the NCA project were notified of the guidelines and offered individual consultation from the Hartford Institute about infusing language about care of older adults into their documents. When requested by specialty associations, the Hartford Institute reviewed an association’s existing documents and offered specific language for incorporating geriatrics. In collaboration with the National Gerontological Nursing Association (NGNA), the Hartford Institute was able to provide individual consultation to specialty associations by gerontological nurses identified by NGNA as having specific skills to provide such consultation.
Successful Inclusion of Geriatric Content into Newly Created and Revised Scope and Standards
To date, 12 specialty nursing organizations have sought and accepted such consultation, and in all, 28 of the 55 association members of NCA have worked on including geriatrics in their scope and standards documents. Communication with associations suggests that the consultation process has been useful in helping them identify opportunities for the inclusion of language about care of older adults. For example, in revising its scope and standards of practice, the American Academy of Ambulatory Care Nursing (www.aaacn.org) found that, once it started the process, there were many ways to emphasize the need to be aware of age-related differences in care. The Academy of Medical-Surgical Nurses (AMSN; amsn.inurse.com) is in the process of updating its scope and standards, and the new drafts have an increased presence of age-related care. Anticipating that the full revision may take some time, AMSN is considering adding an addendum on its Web site in the near future with an update on the care of geriatric clients.
To achieve member buy-in, associations have disseminated and marketed the inclusion of geriatric content electronically and at conferences. The chair of the Ambulatory Nurses Scope and Standards Task Force and the president of the American Holistic Nurses Association, for example, were well received when they explained the processes they used to include age-related content.
What follows are 3 case examples from specialty associations that have included geriatric content while creating new or revising existing documents.
Case Example: The American Holistic Nurses Association (AHNA)
One of the earliest organizations to take on the task was the AHNA (www.ahna.org), which was developing a specialty scope and standards document as part of applying for recognition as a specialty by the ANA. Founded in 1981, the AHNA is an association of more than 3,500 nurses. Holistic nursing is perhaps one of the most universal nursing specialties, with nurses practicing in ambulatory and acute care, wellness and fitness centers, occupational and student health, women’s health, palliative care, and mental health. The AHNA has long been committed to viewing older adults as the most important population cared for by nurses, and its president, Dr. Carla Mariano, has an intense interest in older adults that has guided the integration of content about care of older adults in the scope and standards document. This document is now being used as a model for other organizations seeking to incorporate gerontology in their scopes and standards.
When AHNA began to work on its document, it incorporated the work it had done previously to develop 4 educational modules in holistic nursing and the older population. To create these modules, AHNA had received a grant from the NCA project in 2004. The modules themselves were published online and in print form in 2006.
Carla Mariano, EdD, RN, AHN-BC, FAAIM, associate professor at New York University College of Nursing and a senior advisor for the Hartford Institute, says it is imperative for the elderly to be cared for in a holistic way. Many older people have a variety of health issues, see numerous health care providers, and take multiple medications; they may rely on traditional folk remedies as well and face economic, family, and spiritual issues that influence their health care. Holistic nursing, which focuses on wellness, well-being, healing, and empowerment, is especially well suited to helping keep older people independent and active.
Dr. Mariano has said, “In nursing, we tend to look at the physical almost exclusively, but older people have many emotional and spiritual issues about growing older and the development of their legacy. They have to be looked at in a unified way.”
According to Dr. Mariano, some older people can benefit from complementary, alternative treatments, such as homeopathic remedies or modalities that are oriented to the body-mind-emotion-spirit connection, particularly for chronic problems, such as back pain, that do not respond well to drug treatment. For anxiety and depression, holistic nurses have prescribed successful combinations of relaxation techniques and medication.
In developing its scope and standards document, AHNA infused geriatric content into each standard. In assessment, for example, collection of data must be age-related. Diagnosis must take into account the comprehensive nature of older adults’ health, looking beyond individual symptoms. In terms of planning and defining outcomes, the elderly must be partners in identifying responses to their health or illnesses, incorporating practices that may or may not be part of Western medical treatment.
Case Example: The Cardiovascular Nursing Task Force
The task force represents 15 nursing organizations that are focused on cardiovascular disease (Table 1). It was formed in 2005 to review and revise documents that had not been updated since 1981. Chaired by Eileen Handberg, PhD, ARNP, BC, associate professor of medicine and director of the Clinical Trials Program at the University of Florida, the task force included representatives from each association and from the National Gerontological Nursing Association (NGNA). After 1.5 years of collaborative work, the scope and standards document is now moving through the 2-step ANA review process.
Table 1. Cardiovascular Scope and Standards Participating Organizations
| American Association of Cardiovascular and Pulmonary Rehabilitation |
| American Association of Critical Care Nurses |
| American Association of Heart Failure Nurses |
| American College of Cardiology |
| American College of Cardiovascular Nursing |
| American College of Nurse Practitioners |
| American Heart Association Council on Cardiovascular Nursing |
| American Nurses Association |
| Heart Failure Society of America |
| Heart Rhythm Society |
| International Transplant Nurses Society |
| National Association of Clinical Nurse Specialists |
| National Gerontological Nursing Association |
| Society for Vascular Nursing |
| Preventive Cardiovascular Nurses Association |
The Cardiovascular Task Force was influenced early on by conversations with staff of the Hartford Institute, who described the efforts of NCA to ensure that gerontological issues were being addressed in scopes and standards. Although most cardiovascular nurses work with the elderly as a majority of their practice, the association with the NCA project made the Cardiovascular Task Force more focused and sensitive toward articulating content about the elderly into the document in a more substantive way.
The cardiovascular associations acknowledged not only a growing awareness of the needs of older adult patients but the growing incidence of cardiovascular disease as the population moves toward greater longevity. After the task force began its work, Dr. Handberg says, it was not difficult to address issues related to geriatrics. The association posted the document for public comment on the American College of Cardiology Web site (www.acc.org/qualityandscience/clinical/cvnursing.htm) and received much salient input through the process.
According to Dr. Handberg, cardiovascular nurses tend to be well aware of changes in aging, but one area that required special attention was the need for sensitivity to patients’ changing wishes as they age. The types of interventions performed on a 40- or 50-year-old patient may not be desired by a patient who is 70 or 80 years old. The new scope and standards document emphasizes the need to balance the many types of care and treatment that can be delivered versus the associated risk.
Dr. Handberg said, “When you’re 40, you’re more likely to take those risks. When you’re 70, you may have a different frame of reference. Or maybe you’re a young 70 and want to take those risks, but those caring for you may recommend that you do not. Nurses constantly need to be reminded of the spectrum so they can give person-appropriate care. They can’t assume anything.”
The resulting document, created by the 16 collaborating organizations, is permeated with language addressing differences in aging that cardiovascular nurses must master throughout assessment, diagnosis, and outcomes identification. For example, the diagnosis standard states that a cardiovascular RN must derive diagnoses based on assessment encompassing the needs of the elderly patient regarding posthospital or long-term care. In addition:
as part of autonomous cardiovascular nursing practice, nurses must be educated in patient advocacy across the age spectrum. Starting with nutritional support and avoidance of teratogens at conception, focused education on healthy nutrition and exercise are essential, along with garnering greater public support for the elderly because of their increased incidence of cardiovascular disease.
Dr. Handberg believes that this new cardiovascular nursing resource will affect patient care as part of every training program in cardiovascular nursing and by setting the bar for nursing care in the specialty across numerous settings.
Case Example: the Hospice and Palliative Nurses Association (HPNA)
Like the cardiovascular nurses, hospice and palliative nurses acknowledge that older adults comprise their primary patient population. When the ANA encouraged the HPNA (www.hpna.org) to revise its 2002 scope and standards of practice to include new content and language and to use a new format, the timing coincided with the association’s recognition of the need to address specific populations—from the elderly to children. Through its work with NCA, association leaders had already begun to think about how to clarify the hospice and palliative nurse competencies with regard to older adults.
As an association whose members include the full spectrum of nursing professional from LPN to advance practice, the 9,000-member HPNA is growing as more home care agencies and hospitals become involved in hospice care.
“There is a growing demand for our members,” says Dena Jean Sutermaster, MSN, RN, CHPN, director of education and research for the HPNA.
Despite a preponderance of experience with older-adult patients, there is always more knowledge for members of the APNA to gain—and more ways to use that knowledge, emphasizes Ms. Sutermaster. Lab work should be viewed differently on the basis of the age of the individual, and symptoms, such as a urinary tract infection, may not have the classic symptom of burning but present as confusion and changes in personality.
The HPNA first looked at its scope of practice statement with an eye toward addressing the developmental needs of all patient age groups and ensuring that all of its members were providing age-appropriate care. The association particularly wanted the scope to reflect the increase in hospice care of patients with noncancer diagnoses, such as cardiovascular and respiratory disease.
To the diagnosis standard, the association added that “nurses recognize the influence of age on the patient’s condition when formulating nursing diagnoses.” To the outcomes identification standard for the general and advance practice nurse, the association added the words “utilizes the knowledge that expected outcomes often differ in older adults.”
Conclusion
The scope and standards of practice of any nursing association are intended to comprise a forward-looking, public document that conveys not only the specific skills expected of nurses in that specialty but to a large extent the values expressed by the association. By ensuring that their scope and standards reflect and announce what is expected with regard to care of older adults, the associations profiled here have taken an important step toward ensuring the preparedness of the specialty nurses who will care for the majority of patients in U.S. hospitals, at home, and in long-term care facilities. They will tangibly affect the knowledge and skill levels demanded of nurses hired to work in those specialties, the educational standards taught in nursing graduate programs, and the day-to-day understanding of what is expected of nurses already working in the field.
Through thoughtful and democratic processes, the associations described in this article have created scope and standards documents that will sustain them for several years and can serve as models for other organizations seeking to enhance their members’ competency in caring for older adults. They are showing that it can be done—and it can be done successfully.
References
- . Recognition of a Nursing Specialty, Approval of a Specialty Nursing Scope of Practice Statement and Acknowledgement of Specialty Nursing Standards of Practice. 2005;
- . Standards for nursing practice. 1973;Kansas City, MO
- American Nurses Association. Nursing: scope and standards of practice. 2004. Washington, DC: Available at nursebooks.org.
MATHY MEZEY, EdD, RN, FAAN, is professor and director of The Hartford Institute for Geriatric Nursing, New York University College of Nursing, New York.
CAROL BICKFORD, PhD, RN, BC, is a senior policy fellow, American Nurses Association, Silver Spring, Maryland.
MARY JEAN SCHUMANN, MSN, RN, MBA, CPNP, is the director of nursing practice and policy, American Nurses Association, Silver Spring, Maryland.
CARLA MARIANO, EdD, RN, AHN-BC, FAAIM, is president, American Holistic Nurses Association, and associate professor, NYU College of Nursing, New York.
EILEEN HANDBERG, PhD, ARNP, BC, is associate professor of medicine and director of the Clinical Trials Program, University of Florida, Gainesville, Florida.
DENA JEAN SUTERMASTER, MSN, RN, CHPN, is director of education and research, Hospice and Palliative Nurses Association (HPNA), Pittsburgh, Pennsylvania.
PII: S0197-4572(07)00315-1
doi:10.1016/j.gerinurse.2007.10.010
© 2007 Mosby, Inc. All rights reserved.