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Framework introduction

Definition of nursing practice

Characteristics of advanced nursing
Development of the framework
Implementation of the framework
Evaluation and research
Scope of nursing practice
Values and key components

The nursing practice act
Nursing practice in different settings
Trend in nursing practice
Broadening focusing
Scientific basis
Indication of increasing technology
Expansion of employment opportunity
Nursing public perception
Changing and modern trends in nursing
Advance nursing practice is an umbrella term describing an advance level of
clinical practice that maximizes the use of graduate educational preparation, in
depth nursing knowledge and expertise in meeting the health needs of the
individual, families, group, communities and population. It involves
Analyzing and synthesizing knowledge.
Understanding, interpreting and applying nursing theory and research.
Developing and advancing nursing knowledge and the profession as the whole.


Nursing practice is an act of providing
care to the patient. I n providing care to
the patient the nurses implement a
nursing care is based on initial
condition of the patient. I t is based on
specific nursing theory following
nursing theory and nursing practice
research side by side is must for patient
care and nursing practice

In advance nursing practice nurses builds on their expertise in a
specially area, integrating and consistently displaying the following
feature and characteristics:-
Provision of effective and efficient care, delivered with a high degree of
Demonstrate of leadership and initiation of change to improve client,
organization and system outcomes.
Deliberate, purposeful and integrated use of in-depth nursing knowledge,
research and clinical expertise.

Depth and breadth of knowledge that draws on a wide range of
strategies to meet the needs of client and to improve access to and
quality of care.
Ability to apply and explain the theoretical empirical, ethical and
experiential foundation of nursing practice.
Demonstration of advance judgment and decision making skills.
Critical analysis of and influence on healthy policy.


One of the first priorities of the vice president and CNO (Chief Nursing Office) of the
Calgary Health Region was to developmental of this vision, it became apparent that a
mission for nursing was also essential. As this work progressed, an evident need
emerged to establish a definition of professional practice and a guideline or framework
that nurses could utilize on daily basis to achieve the vision and mission of nursing in
the region.

After several month of consultation with nurses across the region,
discussion at regional nursing council and numerous revisions, the final
draft of professional practice framework was approved by Nursing
Council and distributes during nurse week 2003. The professional
nursing practice framework for the Calgary Health Region.

Implementation Of The Framework
Numerous sessions were held to familiarize nursing staff with the framework
when it was first launched.

Introduction to the framework is now routinely incorporated into the orientation
of all new nurses who join the region

The framework also gives the development preceptors and change nurses.

The major element of the framework next have been linked to the expected RN
and RPN competencies articulated in job description, and application of the
nurses ongoing professional development and continuing education plan.
Evaluation and Research
What facilitate internalization of the professional practice framework?
Did its implementation change nursing practice of select units?
Did changes in nursing practice affects the role of other members of the
health care team/ what difference if any?
Did implementation of a professional practice framework make in job
satisfaction and patient outcomes?
What went well in implementing the framework? What could have been
done differently?

The scope of nursing includes:-
Direct care giving
Evaluation of care and its impact
Advocating for patient and for health
Supervising ad delegating to other
Leading and managing
Conducting research
Developing health policies for health care

The scope of nursing practice is the range of roles, functions,
responsibilities and activities which a registered nurse is educated,
competent and has the authority to perform.

Nursing is both an art and science. It requires the understanding
and applications of specific knowledge and skills and its draws on
knowledge and techniques drive from the humanities and the
physical, social, medical and biological science.

The following are the basis for making decision with regards to the
scope of practice for an individual nurse:-
The primary motivation for expansion of practice must be the
best interest of patient/clients and the promotion and
maintenance for the best quality health services for the

Expansion of the practice must be made in the context of the
definition of nursing and the values that underpin nursing

Expansion of practice must only be made with due consideration to
legislation National policy, local policy and guidelines.
In determining of his or her scope of practice the nurse/midwife must
make a judgment as to whether he/she is competent to carry out the role
The nurse/midwife must take measures to develop and maintain the
competence, communications and evaluations.
Expansion of the practice must be based on appropriate assessment,
planning, communication and evaluation.

The nurse who is delegating a particular role/function (the delegator) is
accountable for the decision to delegate.

The individual nurse is accountable for his/her practice this means that
he/she is accountable for decision he/she makes in determining his/her
scope of practice that included decision to expand or not to expand
his/her practice.

The following values are mentioned below:-

In making decision about an individuals nurses scope of
practice, the best interest of the patient/client and the
importance promoting and maintaining the highest standards of
quality in the health services should be foremost.

Nursing care should be delivered in a way that respects the
uniqueness and dignity of each patient/clients regardless of
culture and religion.

Fundamental nursing practice is the therapeutic relationship
between the nurse and the patient/client that is based on trust,
understanding and support and serve to empower the
patient/client to make life choice.
Nursing profession is accountable for ensuring that its member act in
the public interest and provide the unique service that has been
designated to them by society. This process is called professional

The profession of nursing regulates itself through defining practice,
establishing and developing the public standard of practice and a code
of ethics.

In turn, the state through statues, attests to the public that registered
nurses meet minimal standards for practice and prohibits unlicensed
individual from practicing as registered nurse.
Since each state has legal authority for the regulation of nursing, the
definition and therefore the scope of nursing practice may vary from
state to state.
However the laws remain consistent to protect the public.

The nurse practice act was enacted by the legislature to
regulate the practice for the purpose of protecting the public.

The act does not designed to protect the public from
incompetent nursing, not to protect nurses from discriminatory
or questionable employment practice.

Each nurse is responsible and accountable for making
decision and practicing in accordance with the individuals
educational background and experience in nursing.

Individual RNs
The registered nurse is responsible and accountable,
professionally and legally for determining his/her
professional scope of nursing practice.

Since the role and consequently the scope of nursing
practice, is ever changing and increasing in complexity. It is
important that the nurse makes decision regarding his/her
own scope of practice.
The Nurse Manager And Nurse Executive
The nurse executive in a changing and complex health delivery
system is knowledgeable regarding change in rules and regulation
accreditation standards and standards for care and practice in
addition to evaluation of boundaries specified in nurse practice act.

The nurse executes and/or the nurse manager facilitates changes
to assure quality patient care outcomes and develop mechanism
that will promote the same.

Mobile Nursing Practice
The need was seen in 1984, for local resident to offer extensive care at home.
Reduce the cost and remain in their home for a longer period of time
Organization known as Mobile health care limited and later changed into Mobile
nursing services limited.
Provides care during day and night but previously it was given only on business
This practice is innovative leader in home health are service and transformed this
method to southeast area.
It is a largest and oldest home health care system in that area.
Mobile introduces many innovation in local health care market and continue to do
Mobile Nursing Services
Patient discharge early from hospital
Patient suffering from chronic and
acute medical problems
Surgical patient.
Patient requiring I.V. therapy.
The elderly.
Respiratory patients.
The seriously ill.

Patient in need of medication
Hospice concept
Ventilator dependent
(Assistance) with bathing, dressing,
meals, transportation, light
Service may be covered by Medicare,
medical private insurance, private

These services provide home teaching and care for patient with varied
needs and health problem:-

The military nursing services has its origin from the Army Nursing
Service formed in 1881 part of Royal army.
After the war on 1 October 1926
the nursing services was granted
permanent status in Indian Army
Second World War:-

With the outbreak of second world war, nurses once again found
themselves serving all over the world
During the mid of the war,1943 Indian Army
Nursing services separated from Indian Military
nursing service ordinance. And redesignated as
Military Nursing Service (MNS)
The Military Nursing Service stands out as one of the oldest services where
women have contributed directly to the nations war effort by providing care to the
sick and wounded soldiers; this is true for all the armed forces of the world.

The army nurses have made a permanent place in every Nations
heart by nursing million of sick and wounded soldiers back to
The officers of Military Nursing Services had distinguished
themselves in the Second World War, through the care of the sick
and wounded soldiers in India and also at many foreign threats of
Post independence, the nursing officers cared for the wounded
soldiers in five major bloody conflicts with the neighboring
Commissioned officers
Major- General
Lieutenant Colonel

Refers to the use of telecommunication and information technology for providing
nursing services in health care whenever a large physical distance exists between
patient and nurse, or between any numbers of nurses
As a field it is part of tele health and has many points of contacts with other medical
and non medical application, tele monitoring etc.
Tele nursing is achieving large number of growth in many countries, due to several
factors, the preoccupation in driving down the costs of health care, an increase in the
number of aging and chronically ill, population and the increase in coverage of health
care to distant, rural or small populated region.
Among its many benefits, tele nursing may solve increasing shortages of nurses; to
reduce distance and save travel time and to keep patient out of hospital. A greater
degree of job satisfaction has been registered among tele nurses

The development of nursing robot system included the
development of a mobile robot system to help physically
handicapped people.
Completed in 1986, the nursing Robot was one of the first fully
functioning mobile robots equipped with a manipulators arm,
also integrated with seven different sensor systems.
The system was controlled by four networked on board Sinclair
spectrum computer and on off board IBM-PC.

The nursing robot system comprises their major components; a self
propelled vehicle, a robotic arm mounted on it, and a communication post
next to the disabled persons bed.

Onboard the mobile robot low cost micro-computers are interconnected as
a hierarchical network in order to control a variety of activities, sensor data
processing motion control, path planning, communication and others.

The vehicle can move autonomously in a room with unexpected obstacles.

Nursing in Occupational Health
OHNs are registered nurses who independently observe the assess the workers
health status with respect to job tasks and hazards, using their specialized
experience and education, these registered nurse recognize and prevent health
effects from hazardous exposure and treat workers injuries/illness

OHNs bring their nursing expertise to all industries such as meat packing,
manufacturing, construction as well as the health care industry, OHNs have:-

Have special knowledge of work place hazards and the relationship to the
employee health status.

Understand industrys hygiene principles of engineering controls,
administrative controls, and personal protective equipment.

Have knowledge of toxicology and epidemiology as related to the employee and
the work site.

School Health Nursing
School nurses are primary care nurses for school children. They
work with individual children young people and families, schools
and communities to raising educational standards.

A school nurse is qualified, experienced professional and the only
trained nurse working across health and education boundaries,
they also provide the link between school, home and the
Responsibilities of School Health Nurse
Promoting healthy life style and school
Child and adolescent mental health.
Chronic and complex health care need in children and
young people
Vulnerable children and young people

Activities of school health nurses
Health assessment for children at entrance to the school when
Individual health interviews offered to young people aged 13 -14
Immunization programme.
Child protection.
Health education.

Trends in nursing care closely tied to what is happening to health care in
Trends are fascinating phenomena, but they do not existing in vacuums;
Most are interrelated; one trend often spawns another, although trends are
more than fads,
They are far from money back guarantees. We watch to anticipate the
direction that particular trends will take us, to remove the elements of
when we look back on trends, however, some will have permanent
changes, but other might have temporary.

The focus of nursing has broadened from the care of the ill person to the care
of the people in illness and from care of only the patient to care of the clients,
the family, and in some instance the community.

In the past, nursing like medicine was oriented towards disease and illness.

Today there is increasing recognition of people needs for health care as
distinct from illness care and of the nurses independent functions in this

Another aspect of the broader nursing focus is to the movement of nursing
practice into the community. In a sense there is a return to the beginning of
nursing that is before it becomes a recognized occupation.

Throughout most of this century however nurse worked only in institution,
increasingly nursing services are provided in community often in homes
and clinics.

The nursing activity not only assists those who are ill but also helps those
who are healthy to maintain or continue their health.

Scientific Basis
In the past nursing largely was either intuitive or relied on
experience or observation rather than on research,
through trial and error the individual nurses discovered
with measures that would assist the client and many
nurses become highly skilled in providing care through

Technology or mechanization is being applied in the health
field extensively. Certain areas of a hospital care most
technologic than others. Nurses find themselves in the
midst of rapidly changing, increasingly technologic
environment in hospital and in clients homes.

Indication Of Increasing Technology
The proliferation of the technologic equipment
used in case of client in hospitals and homes.
The increasing home and self care equipment.
Use of computers in many areas of health care.

Many nurses feel they need more
education to obtain the
knowledge and skills necessary
to use the new technology. High
technology has enabled nurse to
gather client assessment data
through non-invasive techniques
(eg:- pulse oxymetry) rather than
the costly invasive procedure.

Expansion of employment
Nursing practice trends include a growing variety of employment setting in
which nurses have greater independence, autonomy and respect as member
of the health care team.

Nursing role continue to expand and develop broadening the focus of nursing
are and providing a more holistic and all encompassing domain.

Nursing therapies are not only drawing from traditional nursing and medicine,
spiritual and emotional realms, but also expanding into alternative therapies
such as healing touch, massage therapy and use of natural herbs and
The Johnson Foundation has developed compelling, attention getting media
campaign on nursing profession.

This media clips show nursing practice, and the nurses featured in the
advertisement and described their satisfaction in the profession, nursing is a
pivotal health care profession, as frontline health care providers, nurses practice
in all health care setting and constitute the largest number of professionals.

Nurses are essential to provide skilled, specialized knowledgeable care, to
improve the health status of the public and to ensure safe effective quality care;
in addition, the American Public rated nurses high in honesty and ethics in their
professional role
Nursing Public Perception
Nursing Impact on Politics and Health Policy
The ability to influence or persuade an individual holding a government office
to exert the power of that office to affect a desired outcome is known as
Political power or influence.

Nurse involvement in politics is receiving greater emphasis in nursing
curricular professional organization and health care setting.

Professional nursing organizations have employed lobbyists to urge state
legislature and the US congress to improve the quality of health care.

Nursing has originated from the word nurturing which means
nourishing, helping in growth and development of a human
being, in the past nursing was family based work.
Modern nursing began in the 19
century under the leadership of
Florence Nightingale.
The aim of nursing was only to promote the recovery of patients.
Even now the central concern of nursing is nurturing the human

The present day nurse provides care for the people in
health services and illness. Nursing is one of the health
services which contribute to well being of an individual,
family and community. Therefore, nursing is defined as a
humanistic science dedicating to maintain and promote
health preventing illness care for and rehabilitation of the
sick and disabled person
Nursing process includes doing, thinking and interaction
component. It is mainly and basically a problem solving approach
of nursing cares. The nursing process consists of five steps

Planning Implementation

. A Rekindled interest in Eastern Religion, lifestyle and medicine has
fueled the development of complementary holistic, alternative
complementary modalities. Client are seeking out
alternative/complementary therapies because most such therapies
are non invasive, holistic and in many instance less expensive than
going to a physician.

In 1993 a landmark survey found 1/3 of the US population had used some
nontraditional alternative method of treatment in addition to the standard
medical treatment.
In 1993 the US Government established an Office of Alternative Medicine at
the National Institute of Health. One of the reason for the OAMs creation was
the US citizens are pursuing alternative methods of health care with
unpredicted enthusiasm.
In 1992, the OAMs was allocated 2 million to investigate the use of
nontraditional treatment methods.
A few therapies investigated by the OAMs -1995:-

Biofeedback to control pain
Acupuncture to relieve depression
Imagery to control Asthma
Ayurvedic medicine to treatment to treat parkinsons disease
Music therapy to treat brain injured client
Shark cartilage to treat cancer

Kozier, Fundamental Of Nursing 5
Edition, page no. 18-21, 40-41.
Lois While Fudamental of Nursing Mosby Publication, Page No.85, 224.
Patricia A. Potter, fundamental Of Nursing 3
edition, Mosby Publication,
Page no.- 29-31
Potter and Perry, fundamental Of Nursing, 5
edition Mosby publication.
Shabeer P. Basheer, A Concise Book of Advanced Nursing Practice 1

edition, 2012, Emmss medical publishers, page no. 648-675.