Professional Association Membership

Professional Association Membership

Examine the importance of professional associations in nursing. Choose a professional nursing organization that relates to your specialty area, or a specialty area in which you are interested. In a 750-1,000 word paper, provide a detailed overview the organization and its advantages for members. Include the following:

  1. Describe the organization and its significance to nurses in the specialty area. Include its purpose, mission, and vision. Describe the overall benefits, or “perks,” of being a member.
  2. Explain why it is important for a nurse in this specialty field to network. Discuss how this organization creates networking opportunities for nurses.
  3. Discuss how the organization keeps its members informed of health care changes and changes to practice that affect the specialty area.
  4.  Discuss opportunities for continuing education and professional development.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. 


Explore the Advocacy page of the American Nurses Association (ANA) website.


Read Chapter 5 in Dynamics in Nursing: Art and Science of Professional Practice.


this is the chapter 5

By June Helbig

“… nurses provide services that maintain respect for human dignity and embrace the uniqueness of each patient and the nature of his or her health problems, without restriction with regard to social or economic status.” (American Nurses Association, n.d.a, para 1)

Essential Questions
  • What significance does joining a professional organization have on nursing practice?
  • How can nurses contribute to legislative changes that impact nursing practice and patient outcomes?
  • Why is evidence-based practice (EBP) the gold standard in patient care protocol improvements?


According to the American Nurses Association (ANA) there are currently 3.6 million registered nurses in the United States (American Nurses Association [ANA], n.d.b, para 12). The ANA is a professional nursing organization, which began when fewer than 20 nurses attended a convention in 1896. Nurses at the time were concerned with nursing practice standards and nurse competency. The ANA has since grown into an organization with interests in improving health care and setting standards for nursing practice. All nurses are represented regardless of status within the organization. The goal of professional organizations is to support nurses and improve the profession (ANA, n.d.c).

This chapter will explore the significance of joining professional organizations and how nursing can contribute to legislative changes that may affect patient outcomes as well as the work environment of the nurse. Professional nursing organizations are responsible for the development and certification of nurses interested in improving health care and providing safe quality nursing care. Through participation in professional organizations, nurses can actively contribute to legislative changes that can affect patient care and the way they conduct their work. Nurses are continually looking for and exploring new ways to provide patients with quality care. Nurses perform studies looking for new and innovative ways to provide care. The use of evidence-based practices (EBP)has become the gold standard for providing safe, quality care to patients.

Standards applied to nursing care include:

  • ANA’s Standards of Practice
  • The Joint Commission’s National Patient Safety Goals (NPSGs)
  • Structured communication tools
  • Integrated health care priorities
  • Quality and Safety Education for Nurses (QSEN)
  • Social determinants of health
  • Cultural competence
  • Healthcare and Research Quality Act of 1999

Standards of Nursing Practice

Standards of practice are rules and regulations that guide the nursing practice. The Nurse Practice Actis a law in each state regulating nursing practice. The National Council of State Boards of Nursing (NCSBN), founded in 1978, requires the licensed registered nurse (RN) to have specialized knowledge, skill, and independence in decision making. Originally, the NCSBN was part of the American Nurses Association Council of the State Boards of Nursing. The NCSBN was created to protect the public from incompetent or unlicensed health care personnel. “The NCSBN has the responsibility of providing regulatory excellence for public health, safety and welfare, and protecting the public by ensuring that safe and competent nursing care is provided by licensed nurses” (National Council for State Boards of Nursing [NCSBN], n.d.a, para. 1).

Information about licensure is available from each state’s board of nursing as well as from Nursys. Nursys “is the only national database for verification of nurse licensure, discipline and practice privileges for RNs and LPN/VNs licensed in participating boards of nursing, including all states in the Nurse Licensure Compact” (, n.d., para 1).

ANA’s Standards of Practice

In addition to the rules and regulations that govern nursing practice, the ANA wrote the Standards of Practice, which are used along with the state Nurse Practice Act to guide safe practice. It is important for the RN with a Bachelor of Science in Nursing (BSN) degree to be aware of the rules and regulations that govern nursing. The standards of practice describe a competent level of nursing practice demonstrated by the critical-thinking model known as the nursing process (Bickford, Marion, & Gazaway, 2015).

National Patient Safety Goals

The National Patient Safety Goals (NPSGs) were established in 2002. The purpose of the NPSGs was to address concerns about patient safety raised by a report from the Institute of Medicine (IOM). The IOM is a Quality Health Care in America committee, which is a division of the National Academies of Science, Engineering, and Medicine.

To Err Is Human

The report, To Err is Human: Building a Safer Health System (Institute of Medicine [IOM], 1999) was a result of two major research studies that found that approximately 98,000 people died each year from medical errors (see Table 5.1). The IOM discovered that these patient deaths were not a result of individual errors, but from a decentralized and fragmented health care system. “Among the problems that commonly occur during the course of providing health care are adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities” (IOM, 1999, p. 1). The IOM also found that many of these errors occurred in areas such as operating rooms, intensive care units, and emergency rooms (IOM, 1999).

Table 5.1
Types of Errors





  1. Error or delay in diagnosis
  2. Failure to employ indicated tests
  3. Use of outmoded tests or therapy
  4. Failure to act on results of monitoring or testing
  5. Error in the performance of an operation, procedure, or test
  6. Error in administering the treatment
  7. Error in the dose or method of using a drug
  8. Avoidable delay in treatment or in responding to an abnormal test
  9. Inappropriate (not indicated) care
  10. Failure to provide prophylactic treatment
  11. Inadequate monitoring or follow-up of treatment
  12. Failure of communication
  13. Equipment failure
  14. Other system failure
Note. Adapted from To Err Is Human: Building a Safer Health System Report Brief, by the Institute of Medicine, 1999, p. 2. Copyright 1999 by the Institute of Medicine.

The IOM committee developed four recommendations to lead the way to making healthcare safer. The first recommendation called for the creation of a National Center for Patient Safety within the U.S. Department of Health and Human Service’s (HHS) Agency for Healthcare Research and Quality (AHRQ). This designated organization would be responsible for establishing NSPGs and tracking their progress. The second recommendation was to create a mandatory reporting system to collect data regarding medical errors. This provided the IOM with a way to track errors and information to prevent future errors and harm. The third recommendation called upon patients, healthcare professionals, and accreditation groups to put pressure on healthcare organizations to provide a safer environment for patients. The only way to find errors within a system is to report errors and then investigate how and why the error occurred.

An error causing an adverse event could have been a patient safety event or an error in documentation. No matter the reason for the adverse event, stopping its cause is paramount. The IOM (1999) report focused on errors that occurred in health care organizations that lead to patient deaths. Analysis of reported errors has revealed many hidden dangers, such as near misses, dangerous situations, and deviations or variations that point to system vulnerabilities, not intentional acts of clinician performance that may eventually cause patients harm (Wolf, 2008). Part of providing quality care is to be aware of events that could occur and could cause harm.

Pressure was applied in the creation of quality indicators, which are measurements of the delivery of quality care. For example, it has been decided the development of hospital-acquired pressure ulcers is a direct indicator of poor care delivery. A patient receiving quality care should never develop a pressure ulcer. So, each month, every organization must report whether any patients developed a pressure ulcer. If so, the organization might not receive the monetary incentive for quality care delivery provided by HHS and Centers for Medicare & Medicaid Services (CMS). Organizations able to prove that zero patients acquired pressure ulcers would receive the monetary incentive.

The last recommendation was to build a culture of safety. “Creating and sustaining a culture of safety would require actions by thousands of health care organizations. Hospital leadership must provide resources and time to improve safety. The organizational culture must encourage recognition and learning from errors” (Donaldson, 2008, p. 5). It is important for all RNs to participate in building and maintaining a culture of safety while working. Those in leadership positions must lead by example in maintaining a culture of safety.

Health care organizations must change and adopt new ways of providing patient care while maintaining a culture of safety. New ways of providing safe care have been developed and are still being developed by conducting studies and finding new and innovative ways for RNs to provide safe, quality care. Hospitals must report errors and explore why errors occurred and what they can do to prevent errors from reoccurring. Safety is now a hospital’s priority.

The Joint Commission

In 2002, The Joint Commission (TJC) established the NPSGs. Health care organizations now have indicators, which are measured to assure a culture of safety. The group that developed the NPSGs was composed of nurses, physicians, and other health care professionals who had first-hand knowledge and experience regarding patient safety. They identified a wide variety of patient safety issues. This group is known as the Patient Safety Advisory Group. They work closely with TJC to continue identifying ongoing issues (The Joint Commission [TJC], 2017).

When issues are found by TJC, the organization must develop action plans to correct any deficiencies that were found and report back to TJC regarding any changes that were implemented. Many times, committees composed of multidisciplinary health care professionals are formed to find solutions for the problems associated with the deficiencies. These deficiencies become the foundation for new safety procedures and regulations that were adopted to correct TJC’s findings.

Crossing the Quality Chasm

In 2001, the IOM published Crossing the Quality Chasm: A New Health System for the 21st Century, which has shaped the future of health care. Again, the IOM’s report found that many patients died in the hospital while receiving care. The IOM believed there was not only a gap in health care that contributed to unnecessary patient deaths but a chasm. Contributing to the problems faced by a rapidly changing system because of advancements in technology and medicine, people were living longer. Living longer leads to an increase in chronic conditions such as heart disease, respiratory illnesses, and diabetes (IOM, 2001). “Crossing the Quality Chasm: A New Health System for the 21st Century focuses on how the health system can be re-invented to foster innovation and improve the delivery of care” (IOM, 2001, p. 2). The report discussed six goals for improvement, which included safety, providing effective medical care, providing patient-centered care in a timely, efficient, and equitable way. The hope was for patients to receive care that was delivered in a safe and reliable environment producing healthier, satisfied patients. As a result, Congress established the Health Care Quality Innovation Fund. The committee listed 10 general rules to follow while redesigning the health care system to achieve safer, patient-centered care (see Table 5.2). Most of what is expected from the BSN-prepared nurse focuses on providing safer, quality care. Knowing the 10 general rules prepares the nurse for the expectation of care.

Table 5.2
Ten Rules for Redesign



  1. Care is based on continuous healing relationships.

Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This implies that the health care system must be responsive at all times, and access to care should be provided over the Internet, by telephone, and by other means in addition to in-person visits.

  1. Care is customized according to patient needs and values.

The system should be designed to meet the most common types of needs but should have the capability to respond to individual patient choices and preferences.

  1. The patient is the source of control.

Patients should be given the necessary information and opportunity to exercise the degree of control they choose over health care decisions that affect them. The system should be able to accommodate differences in patient preferences and encourage shared decision making.

  1. Knowledge is shared and information flows freely.

Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information.

  1. Decision making is evidence-based.

Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.

  1. Safety is a system property.

Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.

  1. Transparency is necessary.

The system should make available to patients and their families information that enables them to make informed decisions when selecting a health plan, hospital, or clinical practice, or when choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice, and patient satisfaction.

  1. Needs are anticipated.

The system should anticipate patient needs, rather than simply react to events.

  1. Waste is continuously decreased.

The system should not waste resources or patient time.

  1. Cooperation among clinicians is a priority

Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.

Note. Adapted from Crossing the Quality Chasm: A New Health System for the 21st Century Report Brief, by the Institute of Medicine, 2001, p. 3-4. Copyright 1999 by the Institute of Medicine.

The reports published by the Institute of Medicine (1999; 2001) both focused on building a safer health care system by providing a culture of safety to provide patient-centered care (see Figure 5.1). The IOM defines patient-centered care as “Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions” (IOM, 2001, p. 3).

Figure 5.1
Patient-Centered Care
The diagram illustrates patient-centered care. The patient is the focal point of the chart and connects outward to eight different aspects of care: access to care; respect for patients' values, preferences, and expressed needs; coordination and integration of care; information and education; physical comfort; emotional support and alleviation of fear and anxiety; involvement of family and friends; and continuity and transition.

fullscreenClick here to enlarge

Note. Adapted from “A 2020 Vision of Patient-Centered Primary Care,” by K. Davis, S. C. Schoenbaum, and A. Audet, 2005, Journal of General Internal Medicine, 20(10), 953-957. Copyright 2005 by the Journal of General Internal Medicine.
Goals Set in Response to Reports

As a part of the IOM reports, the Joint Commission established the first set of the NSPGs in 2002. Initially, there were six goals for the health care system to implement and 11 recommendations by the Patient Safety Advisory Group. By implementing these very specific changes to the health care system, patient care would be safe, and there would be fewer hospital-related deaths.

Table 5.3
National Safety Patient Goals Implemented in 2003

Goal 1

Improve the accuracy of patient identification.

Goal 2

Improve the effectiveness of communication among caregivers.

Goal 3

Improve the safety of using high-alert medications.

Goal 4

Eliminate wrong-site and wrong patient procedure surgery.

Goal 5

Improve the safety of using infusion pumps.

Goal 6

Improve the effectiveness of clinical alarm systems.

Note. Adapted from “Special Edition: JCAHO Patient Safety Goals 2003,” by the National Center for Patient Safety, 2002, Topics in Patient Safety (TIPS), 2(5), p. 2-10. Copyright 2002 by the National Center for Patient Safety.

Many NSPGs are well known by RNs because the goals have become a part of everyday practice. To have no hospital-acquired pressure ulcers, central-line infections, and catheter-associated urinary tract infections are three of the goals for hospitals to achieve. As BSN-prepared nurses, it is important to be knowledgeable and lead other RNs to practice and comply with the standards set forth for patient safety and professional practice. Providing a patient-centered health care experience for the patient is what health care is all about. Having baccalaureate-prepared RNs who are educated regarding the NPSGs will help ensure a culture of safety.

Many of the NPSGs have not changed significantly from what they were in 2003. The goals continue to change and evolve toward providing a culture of safety as new evidence is brought forward. There was another national campaign at the time that focused on providing quality care and ensuring a safe patient environment. The 100,000 Lives Campaign was introduced by the Institute for Healthcare Improvement (IHI). This campaign’s goal was to decrease morbidity and mortality caused by medical errors nationally.

The IOM has continued to focus on improving health care and the health care system. With each new report comes new and innovative ways to build a safer system. In 2010, the IOM and the Robert Wood Johnson Foundation published The Future of Nursing: Leading Change, Advancing Health, which contained four recommendations to advance the practice of nursing:

  • “Nurses should practice to the full extent of their education and training.
  • Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
  • Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.
  • Effective workforce planning and policy making require better data collection and information infrastructure” (National Academies of Science Engineering Medicine, 2015, para. 2).

The importance of these four recommendations affect every nurse. Nurses will now be expected to practice to the full extent of their education and training. Nurse practitioners will be major providers of health care. Becoming a BSN-prepared nurse fulfills the second recommendation of achieving higher levels of education and engaging in lifelong learning. Nurses are now working as members of the health care team in a multidisciplinary environment by partnering with physicians and other health care professionals.

Structured Communication Tools

Structured communication is using a consistent format when providing information. Effective communication was one of the areas the IOM established as an area in need of improvement so hospitals could provide a culture of safety in which patients could receive safe care. In 2008, TJC identified effective communication as one of its NSPGs (Dunsford, 2009). Communication failures were found to result in loss of life. This goal targeted communication not only between physician and patient, but also between patient and all other health care professionals.


In 2002, a group of clinicians revised a tool used by the U.S. Navy for standardizing urgent communication in nuclear submarines (Marshall, Harrison, & Flanagan, 2008) into an effective communication tool for health professionals, which is now known as SBAR communication.

  • Situation: Opening statement to describe the current situation
  • Background: History about the current situation
  • Assessment: Information found upon assessment
  • Recommendation: What the person is requesting to be done

The IHI, established in 1991 to focus on quality improvement in health care, promotes using SBAR for patient safety. The IHI (Institute for Healthcare Improvement [IHI], n.d.a) states the SBAR method of communication “allows for an easy and focused way to set expectations for what will be communicated and how it will be communicated between members of the team, which is essential for developing teamwork and fostering a culture of patient safety” (para. 3). Structured communication is an efficient and accurate method for interdisciplinary communication, which promotes a culture of safety.

SBAR communication is now a widely accepted form of communication when nurses are communicating information to physicians, such as a change in the patients’ condition or reporting newly acquired laboratory values or test results. The letter I, standing for identification, is a recent addition to the SBAR tool. When employing ISBAR communication, nurses should identify themselves before any information is shared, so information is not given to the wrong person. BSN-prepared nurses are responsible for ensuring proper communication occurs between the physician and other members of the health care team.

Table 5.4




To provide your name to the receiver of information

Good morning, Dr. Pasquale. This is Gina calling with information regarding Mr. Enrico.


Opening statement to describe the current situation

Mr. Enrico is requesting pain medication for his back pain.


History about the current situation

Mr. Enrico is a 62-year-old male who was involved in a motor vehicle accident three hours ago.


Information found upon assessment

Mr. Enrico is complaining of severe back pain from his lower back down his left leg. B/P is 170/90, heart rate 112, and respirations are 24. He is afebrile. He has no visible injuries to his back.


What the person is requesting to be done

I am requesting pain medication for my patient Mr. Enrico.

Note. Adapted from SBAR Tool: Situation-Background-Assessment-Recommendation, by the IHI, n.d. Copyright n.d. by the IHI.
Universal Protocol

Another form of structured communication is the Universal Protocol for preventing surgery from being performed on the incorrect patient or on the incorrect site. It also prevents incorrect procedures from being performed on patients. According to the AHRQ (Agency for Healthcare Research and Quality [AHRQ], n.d.), “wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed for preventing wrong-site, wrong-procedure, and wrong-person surgery” (para. 1).

Protecting surgical patients is one of the NSPGs and is called time-out. Time-out was developed to protect the patient from harm when undergoing any procedure. The Universal Protocol starts with a preprocedure checklist to verify the correct patient, the correct procedure, and the correct site. If possible, the patient should be included in this process. The patient, along with the provider, will mark the site where surgery is being done with a marker to assure that the surgery is performed on the correct side. The time-out includes all members of the procedure team, including the physician, nurse, anesthesiologist, and any other active participants in the procedure. When the time-out begins, all members of the team must immediately stop what they are doing and pay attention to the team member who is completing the time-out duties. During the time-out, the team must all agree they have the correct patient, the correct site marked for surgery, and the right procedure to be performed on the patient. The institution where the surgery is being performed may include more verifications. At the end of the time-out, proper documentation must also be completed in the electronic health record (TJC, n.d.). Many times, it is the BSN-prepared nurse who will start the time-out process for the team.

Integrated Health Care Priorities

Patient safety and patient-centered care are two priorities of America’s health care system. One focus of patient care is for health professionals to start providing care in the community by educating the public about prevention of disease and illness. By providing education to the patient, the BSN-prepared nurse may prevent hospital readmissions and keep the patient healthy and at home. Health and wellness have become the priority of many health care providers. The National Center for Complementary and Integrative Health (NCCIH) is the “Federal Government’s lead agency for scientific research on the diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine” (National Center for Complementary and Integrative Health [NCCIH], 2017, para. 1). The NCCIH hopes to find new and innovative ways to provide health care by combining conventional medicine with alternative nonpharmacologic therapies. The NCCIH is conducting research to discover alternative therapies that will promote wellness and prevention (see Table 5.5). Nonpharmacologic therapies are important for the professional nurse to know so alternatives to pain medications can be suggested. The opioid problem in the United States contributes to the need for nonpharmacological alternatives.

Table 5.5
Most Common Nonpharmacologic Therapies



Natural Products

Most Common

Deep Breathing

Yoga, Tai Chi, or Qi Gong

Chiropractic or Osteopathic Manipulation



Special Diets


Progressive Relaxation

Guided Imagery

Least Common

Note. Adapted from “Complementary, Alternative, or Integrative Health: What’s in a Name?” by the National Center for Complementary Care and Integrative Health, 2017b, paras. 12-13, Copyright 2017 by the National Center for Complementary Care and Integrative Health.

Quality and Safety Education for Nurses (QSEN)

The Quality and Safety Education for Nurses (QSEN) project was started in 2005 and is funded by the Robert Wood Johnson Foundation. “The Quality and Safety Education for Nurses (QSEN) project addresses the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSA) necessary to continuously improve the quality and safety of the health care systems within which they work” (QSEN Institute, 2017, para. 1). QSEN has been able to provide educators with information about the numerous quality competencies necessary for nurses to possess in a prelicensure program, as well as RNs who are furthering their education to become baccalaureate-prepared nurses and advanced practice nurses. QSEN also works on providing the KSAs for nurses to provide safe, competent care by educating nurse educators to provide these skills to nursing students. QSEN supports nursing to work within a multidisciplinary environment and to include ancillary services such as social work and case management to be active participants in ensuring patient-centered care. QSEN is also involved in the knowledge, skills, and attitudes for the advanced practice nurse and in strategies to promote curriculum quality. To do this, QSEN provides a repository of information for KSAs, teaching strategies, and faculty development. QSEN is available to any nursing school across the country. QSEN supplies the school with consultants who can help with program planning and curriculum development.

Social Determinants of Health

Social determinants are both internal and external aspects of a person’s life; from diet and lifestyle to income and geographical location. People must be responsible for their health and, therefore, responsible for everything that affects their health. Nurses must educate the public on health, prevention, and wellness, but it is truly the decision of the person to determine whether to act upon what has been taught. People must be active participants in their own health and engaged in preventative health practices. Factors such as environment and access to health care will affect the health of the patient (see Figure 5.2). The combination of genetics and lifestyle will define and dictate a person’s health during his or her lifetime.

Figure 5.2
Social Determinants of Health
The figure represents the social determinants of health (SDOH) by showing one main circle surrounded by five circles that are connected with a single line. The main circle represents SDOH and the five circles represent key areas of SDOH. Starting at the top and moving clockwise, the five circles represent the key areas of neighborhood and built environment, health and health care, social and community context, education, and economic stability.

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Note. Adapted from “Social Determinants of Health,” by, 2018b, Office of Disease Prevention and Health Promotion, paras. 8-9. Copyright 2018 by the Office of Disease Prevention and Health Promotion.

When someone is hospitalized, the goal of the health care system is to provide individualized patient-centered care. Part of the nurses’ responsibility in caring for these patients is to provide instruction on medications, lifestyle changes, and preventive measures to remain healthy and avoid readmission. Each decision regarding compliance with medications and follow-up visits with physicians will affect patients’ health status.

The goal of health care professionals is to keep the public safe while hospitalized and educate upon discharge to prevent readmission to the hospital. It is important for patients to be discharged to a safe environment and to be knowledgeable about illness and the medications that were prescribed. With education, rehospitalization rates should decrease, and the patient can continue to receive health care in the community. People need to be active participants in health to live a long and healthy life. Self-management programs focusing on day-to-day management of chronic diseases have been shown to improve health behaviors and health status significantly. Patient education significantly improves compliance with medication across a broad range of conditions and disease severities (Gold & McClung, 2006).

Table 5.6
Examples of Social and Physical Determinants

Examples of Social Determinants

Examples of Physical Determinants

  1. Availability of resources to meet daily needs (e.g., safe housing and local food markets)
    Access to educational, economic, and job opportunities
  2. Access to health care services
  3. Quality of education and job training
  4. Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities
  5. Transportation options
  6. Public safety
  7. Social support
  8. Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
  9. Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community)
  10. Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)
  11. Residential segregation
  12. Language/Literacy
  13. Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)
  14. Culture
  15. Natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)
  16. Built environment, such as buildings, sidewalks, bike lanes, and roads
  17. Worksites, schools, and recreational settings
  18. Housing and community design
  19. Exposure to toxic substances and other physical hazards
  20. Physical barriers, especially for people with disabilities
  21. Aesthetic elements (e.g., good lighting, trees, and benches)
Note. Adapted from “Social Determinants of Health,” by, 2018b, Office of Disease Prevention and Health Promotion, paras. 8-9. Copyright 2018 by the Office of Disease Prevention and Health Promotion.

Cultural Competence

Cultural competence is learning about, and accepting, differences. These differences define each person as an individual. Nurses cannot let feelings about a specific culture or religion get in the way of providing culturally competent, patient-centered care. Nurses must interact effectively with people of different cultures to ensure the needs of all are addressed (Substance Abuse & Mental Health Administration [SAMHSA], 2016). It is through knowledge of culture and cultural differences that nurses become accepting of those who are different. Nurses must take this knowledge and use it to provide quality care to all patients regardless of cultural differences.

The American Association of Colleges of Nursing (AACN) was in established in 1969 to represent baccalaureate nursing degree and graduate degree education for advanced practice nurses. The AACN’s main responsibility is to establish quality standards for nursing programs, including standards for cultural competence. The AACN has identified five competencies for baccalaureate-prepared nurses to achieve cultural competence (see Table 5.7). Being culturally competent allows the nurse to provide truly patient-centered holistic care. “Holistic care is a term often used in nursing that means to care for patients in their entirety: body, emotions, mind, and social and cultural, environmental, and spiritual aspects” (Cang-Wong, Murphy, & Adelman, 2009, para. 8). Similar competencies were also identified for advanced practice nurses (American Association of Colleges of Nursing, [AACN], 2006).

Nurses must be educated to understand several important terms that are directly related to being culturally competent.

  • Acculturation: occurs when one cultural group learns the traditions and beliefs of another culture. Nurses must learn to accept and adapt to each person being an individual with differing traditions and religious beliefs.
  • Culture: Traditional beliefs and values shared by a common group of people.
  • Cultural Awareness: being knowledgeable about one’s thoughts, feelings, and sensations, as well as the ability to reflect on how these can affect interactions with others (Giger et al., 2007).
  • Cultural Competence: to be respectful and responsive to the health beliefs and practices as well as cultural and linguistic needs of diverse population groups (SAMHSA, 2016, para. 3).
  • Cultural Imposition: the tendency to impose one’s beliefs onto another.
  • Cultural Sensitivity: being mindful of another person’s culture when responding to the person’s needs.
  • Discrimination: prejudicial treatment of another person.
  • Diversity: Variations among people in terms of race, ethnicity, and culture.
  • Health Disparities: Variables that contribute to inequities or unequal distribution of resources for various populations; preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by disadvantaged populations; specifically relatable to social, economic, and/or environmental disadvantages.
  • Stereotyping: preconceived notions of who a person is based on factors such as race, gender, weight, and socioeconomic status.
Table 5.7
The AACN’s Five Cultural Competencies

Competency 1

Apply knowledge of social and cultural factors that affect nursing and health care across multiple contexts

Competency 2

Use relevant data sources and best evidence in providing culturally competent care.

Competency 3

Promote achievement of safe and quality outcomes of care for diverse populations.

Competency 4

Advocate for social justice, including commitment to the health of vulnerable populations and the elimination of health disparities.

Competency 5

Participate in continuous cultural competence development.

Note. Adapted from “Cultural Competency in Baccalaureate Nursing Education,” by the American Association of Colleges of Nursing, 2008, pp. 3-5. Copyright 2008 by the American Association of Colleges of Nursing.
Check for Understanding

Scenario 1

Mary just received her patient assignment for the day, and she sees she had been assigned to Mr. Juarez. This upsets her because he has such a large family, and it is difficult to have to answer so many questions. What are some of the strategies Mary can use while caring for this patient?

Scenario 2

Anne is the charge nurse for a busy telemetry unit. As she is rounding on the patients, she hears the patient down the hall screaming. Anne reaches Mrs. Chun’s room where she finds John, a newly graduated nurse who is in his first week after orientation. Mrs. Chun is quite upset because she does not want John as her nurse. She is very uncomfortable with a male nurse. As the charge nurse, what can Anne do to help Mrs. Chun receive the care she needs?

Scenario 3

Edward is caring for a patient who does not speak English, and he needs to prepare the patient for surgery. How can Edward get consent and teach post-operative expectations?

Healthcare and Research Quality Act of 1999

The Healthcare and Research Quality Act of 1999 was the foundation upon which the AHRQ was built. AHRQ is responsible for improving and assuring the safety of the health care system in the United States. AHRQ develops tools and information available to health care workers and providers to give them the necessary information to make informed health care decisions. In the years since To Err is Human (IOM, 1999) was published, the AHRQ “prevented 1.3 million errors, saved 50,000 lives, and avoided $12 billion in wasteful spending from 2010-2013 (AHRQ, 2017, para. 2).

AHRQ collects data from America’s health care facilities to learn why errors happen. Knowing why something happens is the first step to preventing errors from occurring. The information AHRQ collects is transformed into useful toolkits for health care workers and institutions to use. The toolkits contain the resources, education, and training necessary to be successful in providing a culture of safety. There are currently more than 40 toolkits available for health care improvement. AHRQ also provides data resources about how health care is delivered in the United States (AHRQ, 2017). The topics include:

  • Data infographics
  • Data sources available from AHRQ
  • Healthcare Cost and Utilization Project (HCUP)
  • State snapshots
  • U.S. Health Information Knowledgebase (USHIK)

Health Care Legislation

Health care legislation in the United States is changing all the time, but the goal is for Americans to receive and have access to health care. Nurses care for patients, but they also educate them about wellness and prevention. Many resources available to nurses come from the HHS. The mission of the HHS is to “enhance and protect the health and well-being of all Americans … by providing for effective health and human services and fostering advances in medicine, public health, and social services” (U.S. Department of Health & Human Services [HHS], n.d.a, para. 1). HHS has more than 100 programs available to the public, such as:

  • HIPAA (Health Insurance Portability & Accountability Act) & Your Health Rights
  • Health Insurance
  • Social Services
  • Prevention & Wellness
  • Providers & Facilities
  • Public Health & Safety
  • Emergency Preparedness & Response
  • Research

It is important for nurses to be knowledgeable in these areas so quality care can be provided to the patient. Care is not only physical, and patients have many needs after leaving the hospital or facility. Nurses can direct patients to various government agencies that can provide information about social services, emergency preparedness, and different providers and facilities that the patient may need upon discharge.

Health Care Policy

Health care policies provide rules and regulations regarding health care delivery. The ANA is the professional organization for nurses involved in developing health policy and law. There are processes the ANA must follow to gather information about proposed regulations. “The Administrative Procedures Act requires Executive Branch departments and agencies to publish these in the Federal Register, allow an opportunity for public comments, and take those into account when issuing a final rule or regulation” (ANA, n.d.h, para1). The ANA regularly reviews the Federal Register, which is a daily report about proposed changes to regulations, policies and new executive orders. If the ANA determines that any of the proposals could affect nursing, they submit recommendations to the proposing agency concerning the regulation or executive order. The agency that proposed the change to policy or regulation will take the ANA’s recommendation into account and make changes if accepted. There are 15 agencies that can make changes and proposals to the rules and regulations. These agencies are:

  • AHRQ
  • Centers for Disease Control & Prevention (CDC)
  • CMS
  • HHS
  • Department of Justice (DOJ)
  • Department of Labor (DOL)
  • Department of Veterans’ Affairs (VA)
  • Drug Enforcement Agency (DEA)
  • Food & Drug Administration (FDA)
  • Health Resources & Service Administration (HRSA)
  • National Institute for Occupational Safety & Health (NIOSH)
  • National Institute of Nursing Research (NINR)
  • Occupational Safety & Health Administration (OSHA)
  • Substance Abuse & Mental Health Administration (SAMHSA)
  • U.S. Citizenship and Immigration Services (USCIS) (ANA, n.d.i, para. 2).

Nurses can check the Federal Register, as the information is available to the public daily. Interested nurses can learn about public policy and health care issues that are currently being discussed on the ANA’s website. The ANA is the nurses’ voice in health care policy. An abundance of information is available to nurses through the ANA’s website. Nurses can take many paths after obtaining a baccalaureate degree. Nurses can become politically active, become active in the community and public service, as well as continue in school to obtain an advanced degree. A good way to start is to become familiar with the Federal Register and learn about the changes that affect health care daily.

Decision-Making Process

“One of the key responsibilities of the ANA Membership Assembly is to determine policy and positions for the Association. The meeting of the ANA Membership Assembly provides a forum for discussion of critical nursing practice and policy issues and input from a broad cross section of nursing leaders” (ANA, n.d.j, para. 2).

Concerns addressed by the ANA are in the form of a resolution or position statement. These reports include guidelines for nursing practice.

In December 2016, the ANA delivered a letter to then President-elect Trump outlining the ANA’s Principles for Health System Transformation. (ANA, n.d.f). The principles state that the system must:

“Ensure universal access to a standard package of essential health care services for all citizens and residents.
Optimize primary, community-based, and preventive services while supporting the cost-effective use of innovative, technology-driven, acute, hospital-based services.
Encourage mechanisms to stimulate economic use of health care services while supporting those who do not have the means to share in costs.
Ensure a sufficient supply of a skilled workforce dedicated to providing high quality health care services.” (para 4)

Federal, State, and Local Government

The ANA advocates for nurses on all levels of government. Through the Federal Government Affairs program, the ANA advocates for nurses on the federal level. There are many programs that provide nurses with information and updates regarding federal legislation as well as regulatory issues including promoting “a safe ethical working environment” (ANA, n.d.k, para. 1), advancing “the quality and safety of patient care in transforming the health care system” (ANA, n.d.k, para. 2) and optimizing “professional nursing practice and the quality of health care through leadership development and be ensuring full use of the knowledge and skills RNs and APRNs” (ANA, n.d.k, para. 3).

The ANA’s State Government Affairs program follows bills that are introduced monthly to state legislatures. They track changes that might affect the nursing scope of practice and workplace issues including safe staffing, safe patient handling and movement, mandatory overtime, and workplace violence. The ANA tracks changes made to these areas and shares the information. The state nursing associations become involved in this process as well. The ANA Advocacy Toolkit is available for baccalaureate-prepared nurses interested in supporting nurses in government and taking a political path. The toolkit includes information on how to contact and/or set up meetings with members of Congress and state legislatures (ANA, n.d.l, p. 1).

As a leader, the ANA continues to work to provide nurses with information about changes that are taking place within health care. It is important to know how changes are made and how the individual nurse can contribute to change. It is equally important to know what changes have occurred, so the baccalaureate-prepared nurse can lead that change by participating in committees and mentoring new graduate nurses. What happens in government can affect the nurse, the patient, and even the organization where care is provided. By providing information to nurses and being active in federal and state government affairs, the ANA guides the nursing practice. Some of the reports that are available for nurses detail the ANA principles regarding advanced practice registered nurses, collaborative relationships, and social networking.

Professional organizations are required by law to create a political action committee (PAC), which is a separate part of the organization in order to be active in government and to financially support legislative committees and political candidates. For more than 40 years, ANA-PAC has spoken on behalf of its nurse members before Congress. Some of the issues the ANA is presently working on are health reform, safe staffing, nursing workforce development, and getting appropriate practice guidelines for advanced practice nurses.

Judicial Branch

All branches of government have an impact on nursing and the health care system. The three branches of government are the legislative, executive, and judicial branches. The legislative branch looks at programs and services and decides which programs will be supported and who will pay for the programs. They determine the services that health care workers can provide. The judicial branch is responsible for overseeing and interpreting the laws. “The executive or administrative branch of government develops rules and regulations that further interpret the laws and oversees the implementation of various health care programs” (Jacox, 1997, para. 2).

Advocacy and Activism


Communicating effectively is a very important skill nurses must possess. There are several ways to communicate, and nurses must use and acknowledge all forms of communication, including nonverbal and verbal communication as well as communication via electronic health records. When caring for patients, nurses must be active listeners as well as observe patients for nonverbal communication. Communicating verbally with patients is probably the most common form of communication. Much important communication also occurs via documentation in the electronic health record. The documentation the nurse places into the patient’s chart must be clear and concise, as it is used by physicians and a variety of disciplines, including social work, case management, and other care providers. Nurses who work in a multidisciplinary environment must communicate effectively with all disciplines both orally and through electronic documentation.

This photograph shows a nurse educating a patient on medications and answering any questions the patient may have.

fullscreenClick here to enlargeIn addition to the different forms of communication, a nurse uses different types of communication, which include intraprofessional, interprofessional, and therapeutic communication. Intraprofessional communication takes place in a multidisciplinary environment. It is the communication that takes place when one discipline is providing information to another discipline. Examples include nurse to doctor, nurse to nurse practitioner, nurse to physician assistant, nurse to case manager, and nurse to physical therapist communication. Interprofessional communication takes place when one person is communicating with another person of the same profession. Examples include physician to physician and nurse to nurse communication. Therapeutic communication occurs when speaking with patients. There are many techniques nurses can use to facilitate therapeutic communication. Techniques can be verbal or nonverbal and are used to help the emotional well-being of the patient.

Forms of Advocacy

Many times, nurses work in an environment where collaboration is necessary. Collaboration is when two or more people work to provide safe quality care to patients in a nonthreatening environment. It is important nurses understand they are not alone. They must work collaboratively with all disciplines to ensure patient-centered care. Socialization helps nurses to collaborate effectively.

Advocacy is “the act or process of supporting a cause or proposal” (Advocacy, n.d.). When nurses advocate for patients, stand up for patients’ rights, or work to meet their need for care, that nurse is actively assuming the role of patient advocate. The nurse is using knowledge to care for the patient and to coordinate care for the patient. There are many different types of advocacy. People can be their own advocates or they can advocate for a group or for a specific person, problem, or cause. No matter the cause or the problem, being an advocate is supporting someone or something.


It is important that nurses see themselves as part of the health care team. There are many disciplines involved in patient care, and the nurse is the one who coordinates care between disciplines. The health care environment is changing, especially with the introduction of new technology and information, and the nurses’ role within this new environment is evolving all the time. The nurse must change to meet the daily demands of a changing health care environment. The nurse is the advocate for the patient in this new health care environment, but nurses must also advocate for the profession. Nurses are becoming specialized in care through the many professional certifications that are offered by the ANA. They must use their specialized knowledge as a tool to adapt to change. Health care can be very complicated, and with education such as a baccalaureate degree, nurses now possess the skills and knowledge to adapt to change. The full potential of nurses has not yet been realized. It is important that nurses “work together, across employment settings and roles, to advocate on behalf of colleagues and the profession. Nurses comprise the largest professional group within health care and have been recognized by the public as the most trusted profession” (Tomajan, 2012).

Registered nurses work every day to advocate for the patient and to ensure that proper care is delivered and the needs of the patient are met. The nurse influences and advocates for the care the patient receives through proper assessment of the patient and subsequent communication to other members of the health care team. RNs work collaboratively with other members of the health care team to deliver safe quality patient-centered care and do so by working within the nurses’ scope of practice. The nurse assumes many roles when caring for patients to ensure the patient receives the care needed. The nurse not only provides daily routine care and medications but also acts as the patient’s liaison between all the disciplines he or she meets during hospitalization.

Nursing Involvement

Networking within Organizations to Impact Legislation

Nurses are involved at many different levels of providing care to the patient. Nurses work at the bedside performing 24-hour care, ensuring all the patient’s needs are met. Nurses are part of a multidisciplinary team that includes the physician, social work, case management, respiratory therapy, cardiac services, and the laboratory. Nurses are also primary providers, administrators, leaders, educators, legislators, and senators. Nurses work with patients in facilities, out in the community, and in their homes. “The International Council of Nurses is a federation of national nursing associations that works to enable nurses to speak with one voice so as to influence health policy and advance the profession of nursing” (Benton, 2012).

The ANA is an advocate for the nurse. They support the nurse by raising awareness to problems nurses face. The ANA creates initiatives that raise awareness for the public, and legislators in the state and the federal government. Each of these issues is important and ultimately associated with patients, patient care, and providing a patient-centered safe environment (see Table 5.8). “Nurses not only represent an incredible force by sheer numbers, but policy makers rely upon their expertise as they work to improve our nations’ health system” (ANA, n.d.q, para. 1).

Table 5.8
Nursing Advocacy Examples

Health Care Reform

The [ANA] remains committed to educating the nursing public about how the changing system impacts patients’ lives and the nursing profession (ANA, n.d.m, para 1).

Safe Staffing

“Safe staffing can be a matter of life and death, and getting the right ratios requires nurses and management work together” (ANA, n.d.n, para 1).

Nursing Workforce Development

The ANA is working toward reauthorizing nursing workforce development programs through 2020, including major grant programs for advanced education, work diversity grants, nurse education, practice, and retention grants (ANA, n.d.o).

Handle with Care

“Through Safe Patient Handling and Mobility (SPHM) programs and advocacy, ANA is working to establish a safe environment for nurses, with the complete elimination of manual patient handling as our goal” (ANA, n.d.r, para 3).

Health System Reform

For many years the ANA has been an advocate for the nurse and concerned with health care reform. The goal is for all patients to receive safe quality care. “As the nation’s largest group of healthcare professionals, ANA was instrumental three times in 2017 in stopping the passage of legislation that would undermine the current health care delivery system, impacting nurses and their patients” (ANA, n.d.f, para. 3). As things begin to change with a new administration, the ANA remains active in providing information to nurses about the changing health care environment. The ANA has two publications that are available to nurses to keep up-to-date on current issues: American Nurse Todayand OJIN: The Online Journal of Issue in Nursing.

Workforce Development

Workforce development programs administered by the HRSA are primarily responsible for funding nursing education. The Title VIII of the Public Health Service Act program was expanded previously by the Nurse Reinvestment Act for educational funding. There are several grant programs available for nursing including Workforce Diversity Grants, Nurse Faculty Loan Programs, and Nurse Education, Practice, and Retention Grants. Many of the programs are in response to the need for more nurses to avoid the impending nursing shortage (Health Resources and Services Administration, n.d.).

In 2014, the PPACA recognized nurses as a valuable workforce. The PPACA included provisions for nursing in the Primary Care Workforce Provision as funding for Title VIII programs. They will be providing health care professionals with scholarship and loan repayment plans. Section 5312 of the Nursing and Health Reform section of the PPACA allocated $338 million for nursing workforce programs, including advanced nursing education grants, workforce diversity grants, and nurse education, practice, quality and retention grants (Nursing and Health Reform, n.d., para. 18). Many organizations are encouraging staff to return to school to obtain a baccalaureate degree or advanced practice degree.

Reporting Disparities

Health disparities occur when groups of people receive suboptimal health care. It is usually found to be caused by many factors, including racial bias, religious bias, bias as to age, gender, and sexual orientation, disability, mental health, low income, and low socioeconomic status. Unfortunately, these are not all the reasons that people experience health care disparities, as there are many more. Reducing disparity gives every human being a chance to receive quality patient-centered care, which is what all people deserve. Disparities will be reduced when all people receive appropriate and needed health care.

Disparities in care provided by health care organizations have been occurring for many years. The National Advisory Council on Nurse Education and Practice (NACNEP) (2013) believe that a “diverse workforce is essential for progress toward health equity in the United States.” For the past 10 years, there has been some increase in diversity despite changes that have been made. Some efforts have been successful nationally, but the nurse workforce is not as diverse as expected. Efforts such as the growth of online education and focus on “K-12 Science, Technology, Engineering and Math (STEM) ‘pipeline’ programs have brought more underrepresented minority students into the health professions” (NACNEP, 2013, p. 4).

Efforts are being promoted to achieve more diversity in the nursing workforce. “Grants are funded under Sec. 821 of the Public Health Service Act, 42 U.S.C. § 296m, to increase nursing education opportunities for individuals who are from disadvantaged backgrounds, including racial and ethnic minorities underrepresented in the nursing workforce” (NACNEP, 2013). When diversity is increased, minorities and underserved populations will have access to better care. Communities must be equipped to provide education to engage minorities in health promotion and prevention of disease.

For the past 14 years, the Agency for Healthcare Research and Quality (AHRQ) has been mandated by Congress to provide an overview of the quality of health care in the United States. The AHRQ is assessing whether disparities in care differ among different ethnicities or different socioeconomic groups via quality measures collected each month from across the nation. They define quality as providing patient-centered care in a safe, culturally competent health care environment. AHRQ evaluates whether patients are receiving the right treatments for the right illnesses.

There are about 250 quality measures that AHRQ evaluates, covering many health care services and settings. When evaluating the report, areas of worsening or improving disparities are shown. The report published in 2016 found that quality health care has steadily been improving over the past several years. Areas that are evaluated include patient-centered care, patient safety, healthy living, effective treatment, care coordination, and care affordability (AHRQ, 2016). The report showed that disparities are still present, especially in low-income and uninsured populations. This data is displayed in health care environments across the country on a monthly basis. Nurses take this data and work to improve their scores by participating on committees and becoming active in the delivery of quality care.

Correcting Disparities Through New Health Care Initiatives

There are health care systems across the United States implementing new strategies to create a more diverse health care delivery system. Many of the systems are providing education and training for their workers to provide their diverse populations with quality care. The Health Research and Education Trust (HRET) in partnership with the American Hospital Association conducted a national survey of hospitals across America to discover what hospitals are doing to decrease disparities and to promote diversity in health care (Health Research and Education Trust, 2013). In summary of their findings, it was found that hospitals could communicate better with patients of different ethnicities if they provided cultural competence training and hired a more diverse workforce (Health Research and Education Trust, 2012).

In 2011, the American Organization of Nurse Executives (AONE) published a position statement promoting diversity in health care organizations. They developed four guiding principles for the nurse leader. The focus of the principles was to have health care organizations work toward providing their patient population with patient-centered care regardless of ethnicity or financial status. They urged health care organizations to hire health care workers from their communities that reflect the diversity of the community they serve. AONE asks that local universities, colleges, and nursing schools partner to educate health care workers about diversity. AONE’s guiding principles for diversity in health care organizations include:

  1. Health care organizations will strive to develop internal and external resources that support patient-centered care and meet the needs of the diverse patient and workforce populations served.
  2. Health care organizations will aim to establish a healthful practice/work environment that is reflective of diversity through a commitment to inclusivity, tolerance, and governance structures.
  3. Health care organizations will partner with universities, schools of nursing, and other organizations that educate health care workers to support development and implementation of policies, procedures, programs, and learning environments that foster recruitment and retention of a student population that reflects the diversity of the United States.
  4. Health care organizations will collect and disseminate diversity-related resources and information. (American Organization of Nurse Executives, 2011)

The ANA focuses on diversity and providing each patient with patient-centered quality care. The ANA believes that quality health care is a right for everyone. Nurses need to be cognizant of their patients’ ethnicity and differences to provide them with culturally competent care. The ANA is working to assist professional nurses to meet the needs of an increasingly diverse population and to appreciate the existence of differences in attitudes, beliefs, thoughts, and priorities for these patient populations (ANA, n.d.p).

Evaluation of Health Care Delivery Systems

In 2002, the CMS and the AHRQ brought about measures to evaluate health care delivery and patient experience in the United States. CMS identified six priorities that included making patient care safer, having the patient and his or her family involved in the delivery of care, promoting effective communication, educating the public on wellness and prevention, encouraging more health care delivery from the community, and ensuring that all people have the right to quality health care (Berkowitz, 2016). Together, CMS and AHRQ developed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

The HCAHPS survey is the first national, standardized, publicly reported survey of patients’ perspectives of hospital care (Centers for Medicare & Medicaid Services [CMS], 2017a). Patients’ perspectives are measured from questions asked regarding service during their hospitalization. After hospitalization, patient surveys are sent out asking patients about their experience in the hospital. Nine major areas are evaluated.

  • Communication with doctors
  • Communication with nurses
  • Responsiveness of hospital staff
  • Pain management
  • Communication about medicines
  • Discharge information
  • Cleanliness of the hospital environment
  • Quietness of the hospital environment
  • Transition of care
This photograph shows a meeting of a health care team, including CNAs, nurses, and doctors.

fullscreenClick here to enlargePublic reporting of HCAHPS started in 2008. Consumers are now able to research a hospital’s performance based on patients’ responses to the HCAPHS survey and freely choose their hospital based on the hospitpal’s performance rating. Another program that evaluates hospital performance and the quality of care provided is the Hospital Value-Based Purchasing (VBP) program. Nurses who work in hospitals and facilities that are affected by the VBP are held responsible for the scores received. Baccalaureate-prepared nurses are called upon to lead and participate in committees tasked with improving scores.

The VBP is a CMS initiative that rewards acute-care hospitals with incentive payments for the quality of care they provide to Medicare beneficiaries (CMS, 2017b). Hospitals are no longer paid based solely on the care provided but on the quality of care provided. There are quality domains and dimensions of care that are measured. The HCAHPS score is one of the quality measures for VBP. If the hospital either meets the measure or shows improvement over a previous year’s measure, they will receive the incentive. The quality measures are reviewed each year by CMS.

Prevention Programs

The Surgeon General of the United States (n.d.) has provided several recommendations to eliminate health care disparities. The five recommendations are:

  1. Ensure a strategic focus on communities at greatest risk.
  2. Reduce disparities in access to quality health care.
  3. Increase the capacity of the prevention workforce to identify and address disparities.
  4. Support research to identify effective strategies to eliminate health disparities.
  5. Standardize and collect data to better identify and address disparities.

The National Prevention Council prepared a fact sheet for the elimination of Health Disparities in 2010. The fact sheet contains information on what can be done on the federal, state, and local levels of government as well as what businesses, families, and individuals can do to prevent disparities.

Healthy People 2020 is calling for decreased health care disparities by 2020. Healthy People 2020 believes if people know about the disparities that exist in health care, then maybe those same people would become actively involved in decreasing the disparities that exist. When was first established, its goal for the future of health care was an initiative called Healthy People 2000. They called attention to health care disparities and set a goal to reduce disparities among Americans by the year 2000. For Healthy People 2010, the organization took it a step further, setting a goal to eliminate health disparities. Healthy People 2020 decided to take it a step further and eradicate health disparities, improving health for all (, 2018a).

Reducing disparities should be a goal for all nurses. They must do what they can to ensure that all patients receive the same degree of quality, patient-centered care. Prevention is the only solution. Nurses, especially those who are baccalaureate-prepared, must stand and take a leadership role in reducing disparities in health care. Through continued education and being lifelong learners, nurses will be the ones who will diminish the gaps in health care delivery as the patients’ advocate.

Professional & Organizational Memberships

Significance for Professional Nurses

The ANA represents about 3.6 million nurses and is the largest professional organization in this country. The ANA provides a vast amount of information, making it a valuable tool for nurses. They support nursing in multiple areas, including:

  • Nursing excellence
  • Health policy
  • Work environment
  • Innovation and evidence
  • Advocacy
  • Workforce (ANA, n.d.g)

The ANA supports nursing in many different areas. They are the voice of the nurse in the federal government and are active in all affairs relating to nursing. Each state has a professional organization under the umbrella of the ANA, so they can support nurses on the state and local levels of government. The ANA is one organization a nurse can go to for information about what is happening in nursing and whether there are any new laws that may affect nursing practice. The ANA developed the standards of practice, which, combined with the individual state’s Nurse Practice Act, informs nurses about their scope of practice and the boundaries of a nursing license.

The ANA is a place not only for working nurses, but also for student nurses through the National Student Nurses Association. After joining, the student nurse has access to an online community of student nurses, information about current nursing issues, and full access to the ANA website. Nurses who have not joined the ANA have limited access to the site. The ANA also supports a Nurse Career Center where newly licensed graduate nurses can look for a position. Student nurses and graduate nurses can take advantage of an online community of nurses where they can share their questions about nursing and about the future that is just beginning. When enrolled in the ANA, the nurse is automatically enrolled in their state nursing organization. There are benefits to joining the ANA, but even without joining, all nurses are supported. It is important for BSN-prepared nurses to assume leadership positions and become certified in their specialty. The ANA offers many specialty certifications.

The ANA supports continuing professional development and offers opportunities to become certified in one of the many different nursing specialties (see Table 5.9). Certification offers the nurse the opportunity to become a part of a nursing community with the same interests. Certification is received through the American Nurses Credentialing Center (ANCC). Many times, certification is required for management and leadership positions as baccalaureate nurses prepare for their future.

Table 5.9
ANCC Certification Available

National Healthcare Disaster Certification

Nurse Practitioner Certification

Clinical Nurse Specialist Certification

Specialty Certifications

  1. Interprofessional Certification
  2. Adult Gerontology Acute Care NP
  3. Adult Gerontology Primary Care NP
  4. Family Nurse NP
  5. Pediatrics Primary Care NP
  6. Psychiatric-Mental Health NP
  7. Specialty NP: Emergency NP
  8. Adult Gerontology CNS
  9. Ambulatory Care Nursing
  10. Cardio-Vascular Nursing
  11. Faith Community Nursing
  12. Forensic Nursing – Advanced
  13. Genetics Nursing – Advanced
  14. Gerontological Nursing
  15. Hemostasis Nursing
  16. Informatics Nursing
  17. Medical-Surgical Nursing
  18. Nurse Executive
  19. Nurse Executive – Advanced
  20. Nursing Case Management
  21. Nursing Professional Development
  22. Pain Management Nursing
  23. Pediatric Nursing
  24. Psychiatric-Mental Health Nursing
  25. Public Health Nursing –Advanced
  26. Rheumatology Nursing
Note. Adapted from “ANCC Certification Center,” 2017, by the American Nurses Credentialing Center. Copyright 2017 by the American Nurses Credentialing Center.
Regulatory Body for Nursing Practice

National Council of State Boards of Nursing (NCSBN) is an independent, not-for-profit organization through which boards of nursing act and counsel together on matters of common interest and concern affecting public health, safety and welfare, including the development of nursing licensure examinations (NCSBN, n.d.b).

The regulatory body for nursing is the NCSBN, which is composed of all the individual state boards of nursing. Their main responsibility is to ensure that all people receive safe, competent care. It is the state boards of nursing that regulate nursing programs and oversee licensure of registered nurses. The National Council Licensure Examination (NCLEX) is the licensing exam to become a registered nurse in the United States.

The NCSBN is the legal authority to regulate nursing. The NCSBN collaborates with professional organizations, nurse educators, and other stakeholders to set and enforce the regulations. The NCSBN participates in national nursing education meetings and initiatives. State boards of nursing were created to oversee nursing practice. They achieve this by regulating the education and licensing of nurses who meet all standards. Each state has a law called the Nurse Practice Act, which is overseen and enforced by each state’s board of nursing. The law is composed of four parts:

  1. Education
  2. Practice
  3. Licensure
  4. Discipline

The NCSBN has published position papers and guidelines for many current social issues that may affect nursing practice, such as delegation to other members of the health care team, the use of social media in health care, substance abuse, and medication reconciliation (NCSBN, n.d.c). Any knowledge acquired is beneficial to elevate one’s practice to that of leader or manager.

Accreditation Commission for Education in Nursing (ACEN)

The Accreditation Commission for Education in Nursing (ACEN) provides accreditation for many types of nursing programs including:

  • Doctorate of Nursing programs
  • DNP Specialist certificate
  • Master’s degree programs
  • Post-master’s certificate
  • Baccalaureate degree programs
  • Associate degree programs
  • Diploma programs
  • Practical nursing programs

“Accreditation is a voluntary, peer-review, self-regulatory process by which non-governmental associations recognize educational institutions or programs that have been found to meet or exceed standards and criteria for educational quality” (Accreditation Commission for Education in Nursing [ACEN], 2013). The monitoring of nursing programs is closely related to nursing licensure examinations and the supervision of nursing as a profession. The ACEN is the leading authority of accreditation for nursing, and their goal is to support and advance the profession of nursing. The ACEN strengthens nursing education through the peer-review process, establishing partnerships, supporting self-regulation, and promoting access to education (ACEN, 2013). Nurses who may be looking to obtain a BSN degree will want to know about the school they are attending, so it is important to have quality monitoring of nursing programs and a regulatory agency to provide oversite.

Council for the Advancement of Nursing Science (CANS)

The American Academy of Nursing (AAN) recognized the need for nurses to develop and conduct research studies and publish their findings nationally and internationally to promote nursing science and nursing research. The Council for the Advancement of Nursing Science (CANS) was established in 2000 to help achieve these goals and improve health care through research. At the time, there were four regional nursing research societies in the United States, including the Eastern, Midwest, and Southern Nursing Research Societies and Western Institute of Nursing; the Association of Women’s Health, Obstetric and Neonatal Nurses; Sigma Theta Tau International; and the National Institute of Nursing Research. CANS maintains a partnership with these four research groups (CANS, 2016). Presently, CANS welcomes all nurse researchers and research organizations committed to advancement of health care research.

The Face of the Future

New Health Program Initiatives

Health program initiatives are programs that raise awareness for disease prevention and the improvement of health to promote quality of health care delivery. The CDC provides a list of many health program initiatives that are currently active across the country. Current national health initiatives, strategies, and action plans target topics such as Alzheimer’s disease, chronic diseases such as cancer and osteoarthritis, and cross-cutting topics including health literacy and pain management. Some initiatives are international and include topics such as global health, pandemic strategies, and biosurveillance. These and many more programs exist and for the BSN-prepared nurse who can now assume a leadership position. Having knowledge of these programs is important when providing guidance and resources to patients upon discharge.

The IHI has several strategic initiatives for the improvement of the delivery of health care. One such initiative is the 100 Million Healthier Lives. This initiative is a global initiative to transform the way the world cares for its people. The IHI wants to improve health care globally, so there are 100 million healthier inhabitants (IHI, n.d.b). Another initiative is a call to the leaders of the world to create new and innovative health care delivery systems. Accountable Care Organizations and Medical Homes are two of the programs supported by the Affordable Care Act. Creating an age-friendly health system is another IHI initiative. The IHI (n.d.b) feels that “older adults deserve safe, effective, and patient-centered care (para. 5).” The IHI and the John A. Hartford Foundation formed a partnership to develop new models of health care systems by the year 2020 (IHI, n.d.b).

Registered nurses are leading change by conducting research, which aligns with many of the national health initiatives. Nurses have made significant contributions to the improvement of health care and health care delivery through research. “Nursing research has a tremendous influence on current and future professional nursing practice, thus rendering it an essential component of the educational process” (Tingen, Burnett, Murchison, & Zhu, 2009). Nursing research and evidence-based practice (EBP) are now included in preparation programs for baccalaureate degree nursing programs because of the importance of using best practices to provide care.


Nurses perform research to learn new and innovative ways to provide safe quality health care. Research results provide the evidence that contributes to healthier outcomes and may help to shape health policy. The impact that research has in providing evidence-based practices has affected the way nurses provide care across the continuum of care. It has transformed care delivery, nursing practice, and education. According to the ANA (n.d.d), “Nurses use research to shape health policy in direct care, within an organization, and at the state and federal levels. Nurses conduct research, use research in practice, and teach about research” (para 1).

The federal government has been involved in promoting nursing research for many years. The first program began in 1955, when the National Institute of Health (NIH) established the Nursing Research Study Section. In 1985, the NIH created the National Center for Nursing Research that eventually developed into the NINR, which was established in 1993. The NIH supports nurses conducting and performing research, as well as the training and education of the nurse researcher (HHS, n.d.b).

One of the first EBP protocols to be used by nurses nationally was the result of nursing research through the NINR performed by Dr. Nancy Bergstrom and Barbara Braden. The multisite study investigated the risk of developing pressure ulcers. As a result, the Braden Scale for pressure ulcer risk was found. The Braden Scale is used today in many of the acute-care facilities in this country to score patients daily on pressure ulcer risk (HHS, n.d.b). Depending on what the result of the Braden Scale is, the nurse can actively plan care for the patient to lessen the risk of developing a pressure ulcer. Care planning can include the use of a specialty mattress, skin care products, and a turning and positioning schedule for the patient.

Evidence-Based Practice

EBP is taking what is learned through research and subsequently implementing the results into practice. Nursing research is necessary to advance nursing practice and to promote education and science. By using the results or evidence and clinical expertise, EBP was born. Nurses are making valuable contributions to current health policy, health care delivery, nursing education and practice (Stevens, 2013). “Nurses use research to provide evidence-based care to promote quality outcomes and “to be at the forefront of health care change” (ANA, n.d.e, para 1).

Nurses are active in all branches of research, including conducting research studies and using EBP to provide patients with safe, quality patient care. Many research articles are available for use through the NINR. Nurses can request grants and funding for nursing research projects as well as learn how to conduct a research study. As BSN-prepared nurses, the NINR website can be used to find information about the latest research findings. It enables the nurse to stay current with all the new ways nurses care for patients as well as how nurses can care for themselves.


Since the reports To Err is Human (IOM, 1999) and Crossing the Quality Chasm (IOM, 2001), a goal among all health care professions has been and continues to be the delivery of safe, quality care. One way nurses can improve their practice is through the use of EBP. Nurses never want to do harm, but by doing something the way it has always been done may not necessarily be providing the best care to patients. As a result, nurses have begun to conduct research studies to find better ways to provide care. Hourly rounding is an example of research being brought to the bedside to improve patient safety. When performing a search on hourly rounding, results can be found from research studies years ago to studies currently being performed.

An example of a research study performed recently at an Arizona hospital looked at changing the staffing pattern to improve the quality of care delivery on a 30-bed neuro-stroke unit. The study found that by adding certified nursing assistants to an all RN staff improved the quality of care delivered and the staff satisfaction with employment. By researching new ideas, new practices could be initiated that improve the quality of care provided as well as the satisfaction of the staff. No one knows what will work until research is done that proves or disproves an idea, theory, or hypothesis.

For EBP to be successful, nurses and other health care professionals acknowledge that individual care providers, system leaders, and policy makers in the federal, state, and local governments must be involved. There must also be regulatory actions and recognition for EBP to be adopted. For example, through the Magnet Recognition Program nursing has been a leader in the adoption of EBP, using it as a marker of excellence (Stevens, 2013).

The ANCC sets the standards for Magnet Recognition and recognizes hospitals that meet those standards. One important aspect of Magnet Recognition is the use of EBP. Hospitals that would like to acquire Magnet Recognition must be receptive to nursing research, using EBP, and to provide innovative quality care to patients. Magnet Recognition hospitals are continuously evaluating the research to provide the best care, and it is through their outcomes that quality care is recognized (ANCC, 2017).


EBPs are important not only because they provide patients with the best care, but also for the advancement of the nursing profession. EBP has become the gold standard in patient care protocol improvements. Nurses are more than basic providers of patient care; they are researchers and health care providers. On many units throughout the United States, nurse managers and nurse leaders are conducting research studies to improve patient care and staff satisfaction. There are many different areas in which research could be performed.

Through EBP, health care professionals are advancing medicine and finding new and innovative ways to provide the public with care and education geared to prevention and wellness. The profession of nursing and the public that is served both demand accountability. Nurses are now becoming experts in their field through research and the implementation of EBP. Nurses are continuously researching to improve quality and improve outcomes to ensure that patients receive quality, patient-centered care, regardless of race, socioeconomic status, or sexual orientation. Nurses are transforming health care through evidence-based research and the use of EBP.

Effect on Patient Outcomes

One would think that with the advent of EBP that all Americans would receive safe, quality health care, but this is not true. Receiving patient-centered, quality care is a goal that nurses must continuously strive to meet. Nurses can know what to do, but nurses must also have the proper tools, staff, and environment to guarantee the patient is receiving the best health care. No one lives in a world where everything medically necessary is available to all people. Everyone lives in a world where certain factors can play a major role in the quality of health care all people receive. There are many obstacles to providing quality health care for all, including not enough staff or proper equipment. Thankfully, when EBPs are used, patient care and outcomes have shown to improve health care.

Patient outcomes were first evaluated by Florence Nightingale more than 150 years ago (Cheung, Aiken, Clarke, & Sloane, 2008), and since then, nurses have not stopped asking questions and finding answers. There is a specific science to establishing measurements for improvement. Measurement is very important when implementing change. Measurements can determine whether the changes made were responsible for the improvement or not.

For example, if a nurse were implementing a new patient fall protocol, he or she would need to know historically how many patient falls there were. The nurse would need to know the conditions of the fall and if any injury occurred. A new research protocol was shown to decrease patient falls and how their unit is going to implement the new protocol. To know if it was successful, the nurse would measure patient falls from one date to another. By using this measurement, he or she would be able to determine if the new protocol helped decrease the patient fall rate.

Outcome measurements indicate the effectiveness of the new intervention. The outcome is a result of many factors. There can be factors beyond ones’ control when assessing if a new intervention or protocol is effective. When measuring outcomes, there can be risk adjustments made to consider the unknown factors that may affect the results of measurements. According to the IOM, there are six domains of health care quality (see Table 5.10), which are used when assessing patient outcomes (AHRQ, 2016).

Table 5.10
Six Domains of Health Care Quality


Avoiding harm to patients from the care that is intended to help them.


Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively).


Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.


Reducing waits and sometimes harmful delays for both those who receive and those who give care.


Avoiding waste, including waste of equipment, supplies, ideas, and energy.


Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

Note. Adapted from “The Six Domains of Health Care Quality,” by the Agency for Healthcare Research and Quality, 2016, para. 2. Copyright 2016 by the U.S. Department of Health & Human Services.

Nurses are the largest group of health care providers. Nurses implement evidence-based strategies and work toward providing patients with quality care. Nurses will continue to conduct research studies and reevaluate the care provided to provide safe, patient-centered care to the public. It is through EBP that patient outcomes will continue to improve, and nurses will continue to look for and find new methods to provide safe quality care.

Health Care Policy Enactment

Policies are tools used to implement changes in health care delivery and health care systems. Policies are often successful, but many times they fail as well. Policies can be created on the local, state, and federal levels of government. Until 2010, the creation of Medicare and Medicaid in 1965 was the largest health care legislation to be enacted. In 2010, the Affordable Care Act (ACA) was passed. It was the most significant piece of health care legislation in the United States and was “designed to improve accessibility, affordability, and the quality of healthcare” (Obama, 2016).

Reflective Summary

Whether one has been a nurse for one day or 50 years, each day caring for a patient is a new adventure. It is an adventure in knowing oneself, knowing the patients, making sure that they receive the best care, and feeling a sense of accomplishment. A nurse is never alone; they have coworkers to work alongside them, supervisors to answer any questions, other disciplines to collaborate with to find the best way to provide patient-centered care, and administrators to make sure the environment is safe and the equipment is present and working.

Key Terms

Accreditation: A voluntary, peer-reviewed, self-regulatory process by which nongovernmental associations recognize educational institutions or programs that have been found to meet or exceed standards and criteria for educational quality.

Acculturation: Occurs when one cultural group learns the traditions and beliefs of another culture.

Advocacy: The action of supporting or pleading for a cause or proposal.

Biosurveillance: Performs monitoring of the environment for biologic disease.

Collaboration: Two or more people working together toward a common goal; in a health care setting, this work is meant to provide safe, quality care to patients in a nonthreatening environment.

Competency: An expected level of performance that integrates knowledge, skills, and abilities.

Cultural Awareness: Being knowledgeable about one’s own thoughts, feelings, and sensations, as well as the ability to reflect on how these can affect interactions with others.

Cultural Competence: To be respectful and responsive to the health beliefs and practices as well as cultural and linguistic needs of diverse population groups.

Cultural Imposition: The tendency to impose one’s beliefs onto another.

Cultural Sensitivity: Being mindful of another person’s culture when responding to the person’s needs.

Culture: Traditional beliefs and values shared among a group of people.

Data Infographics: Information provided in a graphic format.

Determinants: “The range of behavioural, biological, socio-economic, and environmental factors that influence the health status of individuals or populations” (New South Wales Department of Health, 2010, p. 6).

Discrimination: “Prejudiced or prejudicial outlook, action, or treatment, the act of making or perceiving a difference” (Discrimination, n.d.).

Diversity: Variations among people in terms of race, ethnicity, and culture.

Evidence-Based Practice (EBP): The integration of clinical expertise, the most up-to-date research, and patient’s preferences to formulate and implement best practices for patient care.

Health Disparity: Variables that contribute to inequities or an unequal distribution of resources for various populations; preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by disadvantaged populations; specifically relatable to social, economic, and/or environmental disadvantages.

Healthy People 2020: A federal program developed by the U.S. Department of Health and Human Services that sets goals related to prominent health concerns and works to achieve them through health education and health promotion strategies.

Health Program Initiatives: Programs that raise awareness for disease prevention and the improvement of health and promote quality of health care delivery.

Health Insurance Portability and Accountability Act of 1996 (HIPAA): Signed into law by U.S. President Bill Clinton granting workers the ability to continue receiving health insurance coverage when changing or losing employment and yielding security and privacy standards for the handling of patient health care information, including electronic transmissions.

Holistic Care: Caring “for patients in their entirety: body, emotions, mind, and social and cultural, environmental, and spiritual aspects” (Cang-Wong et al., 2009)

Hospital Value-Based Purchasing (VBP) Program: A Centers for Medicare & Medicaid Services initiative that rewards acute-care hospitals with incentive payments for the quality of care they provide to Medicare beneficiaries.

Interprofessional Communication: Takes place when one person is communicating with another person in the same profession.

Intraprofessional Communication: Takes place when one profession is providing information to another profession.

ISBAR: Acronym for formal communication tool that stands for Identification, Situation, Background, Assessment, and Recommendation.

Magnet Recognition Program: Program for health care organizations that exceed in providing safe, quality care.

National Council Licensure Examination (NCLEX): Exam required for licensure to become a registered nurse.

National Council of State Boards of Nursing (NCSBN): Organization responsible for providing regulatory excellence for public health, safety, and welfare and protecting the public by ensuring that licensed nurses provide safe and competent nursing care.

National Patient Safety Goals (NPSGs): Goals determined by The Joint Commission (TJC) specifically to improve the safety of patients; promotes and enforces major changes in safety measures for the recipient of health care.

Nurse Practice Act: State laws that ensure nurses provide professional and competent care.

Nursing Standards of Practice: Guidelines developed by the American Nursing Association developed guidelines that govern nursing practice.

Pandemic: Widespread or worldwide epidemic.

Protocol: A procedure routinely followed.

SBAR: Acronym for formal communication tool that stands for Situation, Background, Assessment, and Recommendation.

Socialization: Becoming accustomed to working with others; to be social.

Stereotype: A preconceived notion of who a person is based on factors such as race, gender, weight, and socioeconomic status.

Structured Communication: The use of a consistent format when providing information, such as ISBAR communication.

The Joint Commission (TJC): Independent, nonprofit organization that conducts reviews for health care organization accreditation or program certification. TJC accreditation and certification represents a symbol of quality.

Therapeutic Communication: Use of communication skills that convey a sense of trust and respect to understand the patient’s needs.


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Explore the America Nurses Credentialing Center website. In particular, familiarize yourself with the resources describing standards of practice.


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