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Clinical Nursing Skills

2.3 Practice Standards

Clinical Nursing Skills2.3 Practice Standards

Learning Objectives

By the end of this section, you will be able to:

  • Describe the practice standards that make nursing a professional discipline
  • Identify the scope of professional nursing practice standards
  • Explain the practice standards for nursing delegation

The ANA maintains Standards of Professional Nursing Practice and updates them regularly. These standards are like a trusty map, leading you through the maze of the nursing profession with a dedication to safety, ethics, and excellence as your compass. They provide a foundation for you to make critical decisions and provide safe and ethical care, and empower you to be the advocate, decision-maker, and healer your patients need, while upholding the values of professionalism, compassion, and integrity that define the nursing profession.

Standards of Nursing as a Professional Discipline

As a professional discipline, nursing adheres to a set of standards that guide and govern nursing practice. The ANA’s Standards for Professional Nursing Practice are more than just a set of rules, however: they are the framework for delivering quality care, ensuring that you are equipped with the knowledge and tools to make a positive impact on your patients’ lives (ANA, 2021).

The ANA standards are divided into two main parts. The first six, which ANA calls Standards of Practice, are concerned with the nursing process. They are meant to guide nurses in delivering safe, effective, and holistic care using a systematic approach and critical thinking. Table 2.5 provides more details about these first six standards.

Standard Component of Nursing Process Example
1 Assessment Asking a patient if they are in pain and asking them to rate it on a scale of 0–10.
2 Diagnosis Giving a patient who is awaiting surgery a nursing diagnosis of “Risk for Acute Pain related to scheduled orthopedic surgery as evidenced by patient’s preoperative history of chronic joint pain and planned surgical intervention.”
3 Outcomes identification The nurse identifies a patient outcome of “The patient will report pain levels of 3 or lower on a 0–10 pain scale within 24 hours postsurgery.”
4 Planning The nurse develops and implements an individualized pain management plan for the patient postsurgery, which includes monitoring pain levels, administering pain medications as ordered, educating the patient on pain management techniques, and evaluating the effectiveness of pain relief interventions.
5 Implementation
5A. Coordination of Care
5B. Health Teaching and Health Promotion
During the 24-hour period following surgery, the nurse administers pain medication to the patient according to the prescribed schedule and monitors the patient’s vital signs, including respirations and blood pressure, regularly to ensure pain relief and early detection of any complications. They educate the patient on safe use of pain medications and when to call the nurse for assistance.
6 Evaluation After implementing the pain management plan for a postsurgical patient, the nurse assesses the patient’s pain level on a 0‒10 scale and evaluates the effectiveness of pain relief interventions. If the patient reports a pain level of 3 or lower, and pain behaviors like grimacing have decreased, the pain management plan is considered effective. If not, the plan will be reviewed and adjusted as needed in consultation with the healthcare team.
Table 2.5 Standards of Practice

In addition to the six Standards of Practice, the ANA identifies 11 Standards of Professional Performance. These standards are meant to ensure that nurses maintain competent behavior in their professional role. Table 2.6 provides more details about these standards.

Standard Component of Professional Performance Example
7 Ethics A nurse works at a hospital and has a friend who is admitted as a patient to that same hospital. The friend’s spouse asks to see the medical record belonging to the nurse’s friend. The nurse declines to share the patient record until they speak with their friend, in order to avoid breaking patient confidentiality.
8 Culturally congruent practice A nurse caring for a Muslim patient who is fasting during Ramadan ensures that the patient’s medications are scheduled and administered before sunrise and after sunset when the patient is allowed to eat and drink.
9 Communication A nurse uses clear and simple language free of medical jargon to explain an upcoming MRI to a patient and their family. The nurse encourages questions and actively listens to ensure the patient and family fully understand the procedure, its risks, and its benefits, promoting informed decision-making and reducing anxiety.
10 Collaboration A nurse conducts bedside handoff by involving both the outgoing and incoming shifts of nurses. They discuss the patient’s condition, care plan, and any concerns openly and collaboratively, ensuring accurate and continuous care transition while also involving the patient in the conversation when appropriate.
11 Leadership An experienced nurse takes the initiative to mentor and guide new nurses on their unit, providing them with constructive feedback, sharing best practices, and encouraging their professional development. This leadership fosters a supportive and learning-oriented environment within the nursing team.
12 Education A nurse participates in an interactive online module on the topic of pain management for continuing education credit.
13 Evidence-based practice and research A nurse working in an oncology unit reviews the latest research studies on pain management for cancer patients. They discover a recent study suggesting that mindfulness meditation can significantly reduce pain and improve the well-being of cancer patients. The nurse collaborates with the healthcare team to implement mindfulness meditation as an evidence-based intervention in the unit’s pain management protocols and continuously evaluate its effectiveness with patients.
14 Quality of practice A nursing unit identifies an increase in the number of patient falls. The nursing team collects data on fall incidents, analyzes trends, and conducts interviews with patients and staff to identify contributing factors. They discover that poor lighting in certain areas and inadequate patient education about fall risks are key issues. In response, the nursing unit implements improved lighting fixtures and initiates a comprehensive patient education program on fall prevention. As a result, the rate of patient falls significantly decreases.
15 Professional practice evaluation A nursing manager conducts a regular performance evaluation of nurses on their unit. During the evaluation, they review the nurses’ adherence to infection control protocols, documentation accuracy, communication skills, and overall patient care. This evaluation process helps identify areas for improvement and professional growth, contributing to the nurses’ ongoing development and ensuring high-quality nursing practice within the unit.
16 Resource utilization A nurse working in an outpatient clinic efficiently organizes patient appointments, ensuring that time slots are optimally utilized and patient wait times are minimized. By effectively allocating appointment slots and coordinating patient flow, the nurse maximizes the utilization of available resources while providing timely care to patients.
17 Environmental health In a long-term care facility, a nurse takes steps to maintain a safe and healthy environment for older adult residents. They conduct routine checks for potential hazards, such as slippery floors or tripping hazards, promptly address issues like mold or mildew, and ensure that proper ventilation and air quality standards are maintained.
Table 2.6 Standards of Professional Performance (Source: ANA, 2021.)

Education for Licensure

Education for licensure in nursing involves completing a formal nursing education program that prepares individuals to become RNs. There are two common educational paths to RN licensure in the United States: Associate Degree in Nursing (ADN) programs and Bachelor of Science in Nursing (BSN) programs.

Associate Degree in Nursing programs provide a foundation in nursing knowledge and skills, combining classroom instruction with clinical experiences. Bachelor of Science in Nursing programs include ADN curriculum while also providing a comprehensive education in nursing, including theoretical knowledge, research skills, and clinical experiences. Bachelor of Science in Nursing programs often incorporate courses in the natural and social sciences, as well as additional coursework in areas such as leadership, community health, and evidence-based practice. Upon completion of the ADN or BSN program, graduates must pass a licensure examination called the National Council Licensure Examination for Registered Nurses (NCLEX-RN) in order to become an RN. If desired, the RN may then continue with their education for APRN with more formal specialized training.

Scope of Nursing Practice

The ANA Scope of Nursing Practice defines the boundaries, responsibilities, and expectations of nursing professionals in their respective roles (ANA, 2021). It outlines the specific activities, interventions, and decision-making processes that nurses are authorized and qualified to perform within their jurisdiction. By defining these roles and responsibilities, the Scope of Nursing Practice serves several purposes.

Clearly defining the activities and interventions that nurses are competent to perform may help prevent nurses from engaging in practices beyond their scope of knowledge and skills, thereby minimizing the risk of errors, adverse events, and harm to patients. It also helps establish professional boundaries by clarifying the limits of nursing practice and ensures that nurses understand both the extent of their role and responsibilities and the appropriate times to seek assistance or refer patients to other healthcare professionals. This helps maintain clarity and accountability in nursing practice.

The Scope of Nursing Practice also sets standards for quality and consistency in nursing care. It ensures that nurses possess the necessary competencies, qualifications, and knowledge to provide safe and effective care. By adhering to the defined scope, nurses contribute to the delivery of evidence-based, standardized care that meets the needs of patients and promotes positive health outcomes. Additionally, the scope provides a foundation for nursing education and professional development. It helps shape nursing curricula, ensuring that educational programs equip students with the necessary knowledge and skills to practice within their field of study. It also guides nurses in identifying areas for further education and specialization, promoting lifelong learning and professional growth.

Another purpose of the Scope of Nursing Practice is to protect the public and regulate the nursing profession. It helps establish legal and regulatory frameworks that govern nursing practice, ensuring that nurses adhere to ethical standards, maintain competence, and provide safe and ethical care. It also provides a basis for licensure, certification, and disciplinary processes that maintain professional accountability and public trust.

Finally, the Scope of Nursing Practice facilitates collaboration and fosters positive relationships among healthcare professionals. It delineates areas of overlap and collaboration with other members of the healthcare team, promoting effective communication, coordination, and shared decision-making. This leads to improved patient outcomes and a more holistic approach to care.

Real RN Stories

Remaining Within Your Scope of Practice

Nurse: Johanna, RN
Clinical setting: Emergency department of a small, rural hospital
Years in practice: 2
Facility location: Pennsylvania

As an RN who works in the emergency department, I often encounter various situations that demand quick thinking. One day I found myself in a situation where a concerned family member asked me to interpret a brain MRI scan for their loved one who was being treated for a head injury.

The family member was visibly worried and eager for answers. They asked me to look up the patient’s chart on my computer and review the MRI images and explain what was happening. I understood their anxiety, but I knew that interpreting radiological images, such as MRIs, fell outside the scope of my nursing practice.

I explained to the family member that while I could provide information about the patient’s overall condition and care plan, I wasn’t qualified to interpret the MRI scan accurately. Radiology interpretation requires specialized training and expertise and is usually provided by radiologists.

I let the family member know that our healthcare team would ensure that the MRI results were reviewed by a qualified specialist as soon as possible who could provide a detailed interpretation. I also mentioned that the attending physician would discuss the findings and treatment plan with them once the interpretation was available.

While the family member seemed disappointed, they appreciated my honesty and understanding. They understood that my primary role was to provide safe and compassionate nursing care, and I had their loved one’s best interests in mind by ensuring that the MRI was reviewed by the appropriate specialist. This experience reinforced the importance of staying within the boundaries of my scope of practice.

Decision-Making Framework

The Scope of Nursing Practice Decision-Making Framework was developed by professional nursing organizations as a tool for nurses and others to determine what actions a nurse may safely perform (Ballard et al., 2016). It guides nurses in navigating complex situations, ensuring that their actions align with their scope of practice and adhere to ethical and legal standards. The tool is intended for use by direct care nurses, managers, educators, administrators, researchers, and others.

Practice Standards for Delegation

An essential nursing skill, delegation involves assigning a task to another person who has the appropriate knowledge, skills, and competence to perform that task (ANA & NCSBN, 2019). The delegating nurse retains responsibility and accountability for the outcome of the delegated task. Delegation allows nurses to distribute workload, prioritize care, and optimize efficiency (Table 2.7). By utilizing the skills and capabilities of other members of the healthcare team, it helps ensure that patient needs are met. However, the RN may not delegate tasks related to making nursing judgments, critical decision-making, or clinical reasoning such as initial assessment, evaluation, teaching, and advanced training.

Assessment and planning Evaluate needs and plan for delegation.
Task and delegate selection Choose appropriate tasks and qualified individuals.
Communication and resource provision Ensure clear communication and necessary resources.
Supervision and evaluation Oversee task completion and assess outcomes.
Documentation and accountability Maintain records and ensure accountability.
Table 2.7 Key Steps of Nursing Delegation

Five Rights of Nursing Delegation

The ANA’s “Five Rights” of nursing delegation are a framework that helps guide the delegation process and ensure safe and effective care delivery (ANA, 2019). These rights provide a systematic approach to delegation and help nurses make informed decisions about assigning tasks to other healthcare team members. Table 2.8 lists the Five Rights of Delegation.

Right What the Right Entails
Right task The task must be appropriate for delegation.
Right circumstance The circumstances must be appropriate for delegation.
Right person The individual must be able to perform the task.
Right communication The instructions regarding the task must be clear.
Right supervision The individual performing the task must be properly supervised.
Table 2.8 Rights of Nursing Delegation

Right Task

The first right of delegation is ensuring that the task being delegated is appropriate for delegation. The task should be one that can be safely and effectively performed by the delegate based on their education, training, and competence. It may not be a task related to clinical reasoning, nursing judgment, or critical decision-making.

Right Circumstance

The second right of delegation involves considering the circumstances under which the task is being delegated. Nurses must evaluate factors such as the patient’s condition, stability, and complexity of care needs, as well as the availability of resources and support. Delegation should be appropriate given the specific situation and the delegate’s ability to carry out the task effectively. For example, delegation of basic care to a critically unstable patient would not be appropriate; this task should be performed by the nurse in case the patient’s condition changes rapidly.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Safety: Delegation

Disclaimer: Always follow the agency’s policies regarding delegation.

Definition: This competency centers on nurses’ capacity to correctly employ a structured decision-making framework in their practice. It ensures that nurses have the necessary knowledge, skills, and attitudes to make informed, evidence-based decisions that optimize patient outcomes while considering patient preferences, values, and ethical principles.

Knowledge Areas:

  • Clinical Judgment: Nurses should possess a deep understanding of clinical judgment, enabling them to assess patient data, discern patterns, and make informed decisions rooted in the best available evidence.
  • Evidence-Based Practice: Competency in evidence-based practice involves the ability to integrate current research findings into decision-making, ensuring the delivery of the most effective and up-to-date care.
  • Ethical and Legal Principles: Nurses must be well-versed in ethical and legal considerations to navigate complex ethical dilemmas and adhere to regulatory standards in their decision-making.

Skill Areas:

  • Critical Thinking: Proficiency in critical thinking is essential for evaluating and analyzing information, identifying potential risks, and weighing the benefits and drawbacks of various interventions.
  • Communication and Collaboration: Effective communication with the healthcare team, patients, and their families is vital in decision-making. Nurses should actively engage in interprofessional collaboration to ensure comprehensive patient care.
  • Patient-Centered Care: Nurses should involve patients in the decision-making process, considering their values, preferences, and cultural background to develop a care plan that aligns with the patient’s goals and needs.


  • Patient Advocacy: Nurses should uphold a commitment to patient advocacy, ensuring that patients’ voices are heard and their choices respected in the decision-making process.
  • Lifelong Learning: Embracing a commitment to lifelong learning is essential, enabling nurses to stay updated with advances in health care and evolving best practices to continuously improve their decision-making skills.

Right Person

The third right of delegation focuses on selecting the appropriate individual to whom the task will be delegated. Nurses should assess the delegate’s knowledge, skills, and competence in performing the delegated task. Consideration should be given to their experience, training, and ability to handle the specific task safely and effectively. For example, nurses will not delegate medication administration to unlicensed assistive personnel (UAP), as that is not within their scope of practice.

Right Communication

The fourth right of delegation emphasizes the importance of clear and effective communication. Nurses must provide clear instructions and guidelines to the delegate regarding the task to be performed. This includes explaining the purpose and desired outcomes as well as any specific instructions and potential risks or precautions associated with the task. Communication should be ongoing and include feedback and clarification as needed.

Right Supervision

The final right of delegation involves appropriate supervision and evaluation of the delegated task. Nurses maintain responsibility for overseeing and evaluating the care provided by the delegate. They must provide ongoing support, guidance, and feedback, and monitor the delegate’s performance to ensure the task is carried out safely and effectively. Regular communication and follow-up are essential to ensure the task is completed satisfactorily and any necessary adjustments are made.

Clinical Judgment Measurement Model

Generate Solutions: Deciding When It Is Appropriate to Delegate

Generating solutions involves identifying the different actions or interventions available to address a patient issue. This requires recognizing which solutions are indicated and/or effective, and which are unnecessary or contraindicated. Delegating care is a critical part of generating solutions in nursing, as multitasking and prioritizing remain consistent top priorities. The Five Rights of Delegation provide a framework for critical thinking to assist the nurse in the delegation process. For example, a nurse has a patient who needs their blood glucose checked just prior to a meal, but another patient’s heart rate has suddenly dropped from the 80s to the 40s on the telemetry monitor. There is a UAP available to help, and the nurse uses the Five Rights of Delegation to determine that they will go check on the patient with the low heart rate, the critical situation, while the UAP checks the blood glucose of the other patient.


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