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Letter to the Editor

Best Practices for Developing Specialty Nursing Scope and Standards of Practice

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Deborah S. Finnell, DNS, APRN-BC, CARN-AP, FAAN
Elizabeth L. Thomas, MEd RN, NCSN, FNASN
Wendy M. Nehring, RN, PhD, FAAN, FAAIDD
Kris A. McLoughlin, DNP, PMHCNS-BC, FAAN
Carol J. Bickford, PhD, RN-BC, CPHIMS, FAAN

Abstract

Nursing specialization involves focusing on nursing practice in an identified specific area within the entire field of professional nursing. A defined specialty scope of practice statement and standards of professional practice, with accompanying competencies, are unique to each nursing specialty. These documents help assure continued understanding and recognition of nursing’s diverse professional contributions. The purpose of this article is to demystify the process for specialty nurses who are creating or revising their specialty nursing scope and standards of practice. We provide best practices for the developmental process based on our recently published scope and standards of specialty nursing practice. The conclusion provides strategies to disseminate scope and standards documents to appropriate stakeholders.

Citation: Finnell, D., Thomas, E., Nehring, W., McLoughlin, K., Bickford, C., (May 31, 2015) "Best Practices for Developing Specialty Nursing Scope and Standards of Practice" OJIN: The Online Journal of Issues in Nursing Vol. 20, No. 2, Manuscript 1.

DOI: 10.3912/OJIN.Vol20No02Man01

Key words: scope and standards of nursing, specialty nursing, nurses, professional nursing, best practices, American Nurses Association, addictions nursing, school nursing, correctional nursing, psychiatric mental health nursing, intellectual and developmental disabilities nursing

Grounded in the profession of nursing, areas of focused nursing practice have emerged as nursing specialties. The American Nurses Association (ANA) document, Nursing: Scope and Standards of Practice (in press), describes what nursing is, what nurses do, responsibilities for which nurses are accountable, and the outcomes of that practice. Nurses are responsible for the direct care delivery and the consequential outcomes, specified in that ANA foundational document. Grounded in the profession of nursing, areas of focused nursing practice have emerged as nursing specialties.

Associated nursing specialty organizations are designated stewards of specialty nursing knowledge and seek publication of the specialty nursing scope of practice statement and standards to delineate and guide that unique practice. Registered nurses at the national and international level, as well as other stakeholders engaged in legal, regulatory, administrative, education, and research activities, value scope and standards documents. These documents help to assure continued understanding and recognition of the diverse professional contributions of nurses.

Registered nurses at the national and international level... value scope and standards documents. Developing the scope and standards of specialty nursing practice can be a daunting task for the nurse experts leading the work. The purpose of this article is to demystify that process, whether to create new or revise existing specialty nursing scope and standards of practice. We discuss best practices incorporated in the developmental process for several recently published scope and standards of specialty nursing practice. These best practices are applicable to nursing specialty organizations publishing with ANA, as well as those that are not. This article addresses each of the following best practices in detail: utilizing structures and processes to initiate the process; identifying a lead writer for the process; convening experts with specific roles and functions; ensuring incorporation of foundational documents; establishing a realistic timeline; addressing strategies to overcome barriers; promoting facilitators for success; responding to reviewer feedback, and disseminating the Scope and Standards.

Best Practices for Scope and Standards Development/Revision

Utilizing Structures and Processes to Initiate the Process

ANA has published a resource that outlines recommended steps for development of specialty nursing scope and standards documents, Acknowledgement of Specialty Nursing Standards of Practice and Acknowledgment of Practice Standards (ANA, 2010a). Thought leaders in specialty nursing organizations are advised to begin by addressing the following six key questions:

  1. Who? Identify numbers of nurses, professional organization/society, and educational preparation.
  2. What? Explain the unique contributions of generalist and advanced practice registered nurses.
  3. When? Determine when these specialty nurses are needed.
  4. Where? Describe practice environments in sufficient detail to understand specialty practice.
  5. Why? Determine what niche or gap is filled; the historical perspective of the development of the specialty; current issues and future trends in health care that point to the need for the specialty.
  6. How? Identify the process to become this type of nurse specialist, including development through formal education, continuing education, and practice experiences. Address use of the nursing process and the Code of Ethics (ANA, 2015).

Nursing specialty organizations may elect to partner with the ANA in this process. In this case, the organizations collaborate throughout the process of review and revision, leading to the intended outcome of a final approval by the ANA Board of Directors.

Associated nursing specialty organizations are designated stewards of specialty nursing knowledge ... Some specialty organizations have a strong history in publishing nursing standards, predating their recognition by the ANA. For example, Lina Rogers Struthers, the first nurse assigned to schools from the Henry Street Settlement, published The School Nurse in 1917, only fourteen years after the beginning of school nursing in New York City (Struthers, 1917). In 1983, the first ANA published standards for school nursing practice were released, followed by five revisions. In 1998, the National Association of School Nurses (NASN) and ANA began a co-publishing partnership for the standards of practice. NASN added a scope of practice statement in 2001 (ANA/NASN, 2011, p. 6).

Significant changes in the evolving healthcare and nursing practice environments require that specialty nursing standards be reviewed, revised as necessary, and resubmitted to ANA for acknowledgment at least every five years, or more frequently if warranted (ANA, 2010a). As the convener and steward for the ongoing work, the ANA prompts nursing specialty organizations in advance of the five-year publication mark.

An effective strategy is to simultaneously develop the scope and standards and the application for specialty recognition. In select instances, nursing specialty organizations also need to seek ANA recognition of a new nursing specialty when submitting the specialty scope and standards document to the ANA review process. An effective strategy is to simultaneously develop the scope and standards and the application for specialty recognition.

Identifying Lead Writer for the Process

Historically, leaders in nursing specialty organizations have undertaken the actual writing of their scope and standards in various ways. For example, the ANA convened the correctional nursing workgroup, and the ANA staff served as the custodian of the correctional nursing scope and standards document. The ANA compiled small groups’ writing outputs, and created draft documents for review by the entire workgroup. The workgroup’s draft document for public comment was posted by the ANA. The group then finalized the document for submission to the ANA review process.

Some nursing specialty organizations intentionally maintain the lead writer who directed the development of earlier editions (e.g., Intellectual and Developmental Disabilities Nursing: Scope and Standards of Practice, ANA/American Association on Intellectual and Developmental Disabilities, 2013), providing continuity over time. Still other organizations utilize the previous editor to mentor a new volunteer (e.g., Addictions Nursing), providing a process for succession planning. Lead writers may also be designated by a nursing specialty organization Board of Directors, such as with the Psychiatric Mental Health Nursing: Scope and Standards of Practice, Second Edition (ANA, American Psychiatric Nurses Association [APNA], & International Society of Psychiatric Mental Health Nurses [ISPN], 2014). In this example, two specialty organizations, the APNA and ISPN collaborated on the single document.

Lead writers assume their roles with the understanding that their scope and standards document serves as a reference source... Lead writers assume their roles with the understanding that their scope and standards document serves as a reference source for nurses seeking specialty certification, nurse-specialists, legislators, regulators, legal counsel, the judiciary system, various health care agencies/organizations, nurse administrators, other nurses not working in this specialty, other interprofessional colleagues, and healthcare consumers (ANA, 2010a). The specialty scope and standard document articulates the role and responsibilities of registered nurses and advanced practice registered nurses who work in a respective nursing specialty. Thus, in developing the scope and standard document, nursing specialty organizations rely on additional expert volunteers to contribute to the development of a high quality product.

Convening Experts with Specific Roles and Functions

Contributors to the process of creating a specialty scope and standards document are sought in various ways. The broadest approach is via an ANA call for member participation, including messages to state nurses associations and organizational affiliates. This strategy can generate a large number of nurses in the specialty, yet requires a selection process to identify the most qualified volunteers. The specialty organization’s board of directors may also solicit volunteers, an approach recently used by APNA and ISPN, with each organization selecting five participants that represented the various educational levels and foci for psychiatric mental health nursing.

... contributors have usually included nationally and/or internationally recognized nurse experts in the specialty. Nursing specialty organizations (e.g., school nursing) have sometimes taken additional steps to ensure geographic representation, in addition to expertise in academe and direct and indirect roles in public, private, and state facilities/agencies. Other strategies have included targeted selection of specialty nurses known for their expertise, published scholarly work, and other significant contributions to the specialty (e.g., Addictions Nursing, and Intellectual and Developmental Disabilities Nursing). Overall, contributors have usually included nationally and/or internationally recognized nurse experts in the specialty. Another expectation of contributing writers is a solid understanding of the ANA’s foundational documents that ground the scope and standards of practice.

Ensuring Incorporation of Foundational Documents

Specialty nursing organizations undertaking a revision have traditionally incorporated concepts and content from the foundational documents of the ANA in their scope and standards. These foundational documents may include the Code of Ethics (ANA, 2015), Nursing’s Social Policy Statement: The Essence of the Profession (ANA, 2010b), and Nursing: Scope and Standards of Practice, Third Edition (ANA, in press). Whether an initial undertaking or revision, successful integration of the content of these resources in the scope and standards entails reading, reviewing, and repeatedly returning to these primary foundational source documents for guidance.

As the document evolves, small groups may be designated to carefully review drafts for specific content to ensure that the nursing specialty organization’s scope and standards does actually build upon these source documents. An exemplar of such work is the Correctional Nursing: Scope and Standards, Second Edition (ANA/Corrections Nursing, 2013) which articulates specialty exemplars for the nine provisions of the Code of Ethics. The Committee on Nursing Practice Standards (CNPS), which reviewed this document, utilized it as an exemplar for subsequent nursing specialty organization developing or revising their scope and standards. For example, in providing feedback to the Addictions Nursing and Psychiatric Mental Health Nursing groups, the CNPS encouraged both to develop a similar narrative for the nine provisions. This ultimately extended the timeline for finalizing their work; however, each group elected to revise accordingly, and felt that this extra content substantively enriched the final documents.

Establishing a Realistic Timeline

In planning the timeline, lead writers need to keep in mind that writers are volunteers, with other competing responsibilities and priorities. At a minimum, writing groups should plan a 12 to 18 month period from the onset of the project to acceptance of the scope and standards by the CNPS. However, the process can take as long as 24 to 36 months. Larger groups may even require additional time to reach to consensus. Work that entails collaboration among different nursing specialties may also extend the timeline when approval is required by the various boards of directors. In planning the timeline, lead writers need to keep in mind that writers are volunteers, with other competing responsibilities and priorities.

Addressing Strategies to Overcome Barriers

Even with the best plan, there are often barriers that can impede a timely outcome for the project of a collaborative group. Previous contributors to workgroups identified the following barriers and potential strategies related to time constraints, the writing process, and logistics.

Getting and giving clear directions from the onset is invaluable to assure forward progress. Time constraints. Nearly all contributing authors identified the challenge of adhering to the timeline while working with busy professionals whose time constraints were significant and many. Several effective strategies helped to overcome this barrier. One strategy included establishing the best time of day for meetings. In multiple instances, that meant evening conference call meetings. Some found it useful to meet frequently, yet limit the duration of meetings, while others met for longer periods of time at less frequent intervals.

The writing process. To avoid or minimize time-consuming revisions, one recommendation is to contact ANA staff prior to starting the writing process. Getting and giving clear directions from the onset is invaluable to assure forward progress. The challenges of volunteers aside, some writers did not produce as expected. Thus, it is helpful to anticipate potential reassignment of work. Some leaders identified the variability of writing skills across contributors. Thus, the lead writer needs to assume the ownership of writing the document to ensure it is cohesive and in a “single voice.” 

 As the work is nearing completion... select a subgroup who will take responsibility for the revisions leading to the final document. Logistics. Handling multiple versions of the document often presents a challenge. One strategy offered is to utilize free or low cost online storage programs, such as DropBox (www.dropbox.com) or Google Docs (www.google.com) accessible to all. This process can be an effective way to communicate changes among the team members and manage multiple and ongoing revisions. As the work is nearing completion, another strategy is to select a subgroup who will take responsibility for the revisions leading to the final document.

Promoting Facilitators for Success

Establishing ground rules was important, including respect for diverse ideas and opinions. A common theme across all leaders of the scope and standards workgroups represented herein was the importance of forming the group and quickly developing cohesion. Establishing ground rules was important, including respect for diverse ideas and opinions. Another common theme was that the contributors were enthusiastic and committed to providing a quality product. Despite an all-volunteer group, individuals worked tirelessly to “get it right.” Thus, developing an effective working team who are focused on a common goal was critical to the process.

A track record of strong, effective organizational skills of the lead author was invaluable facilitator for success. Effective strategies included developing a project plan with targeted activities, identifying responsible persons, and setting realistic target dates for completion. Lead writers were mindful of matching writing assignments to the specific expertise and strengths of group members. For example, historians were important for telling the story of the development of the nursing specialty.

...historians were important for telling the story of the development of the nursing specialty. Lead writers were also mindful of the need to both delegate and attend to deadlines. Strategies for management included regularly scheduled meetings and individual follow-up with particular group members. For most, the initial group meetings tended to be longer (e.g., two-hour conference call) and frequent (e.g., monthly). As work progressed, shorter and less frequent meetings were required.

As group members contributed their respective writing assignments, lead authors assumed the role of melding the works into a cohesive working document. This role drew on the lead authors’ editorial skills to ensure that the final product was, as one said, “in ‘one voice,’ yet the work of several contributors.” At various stages of the development process, lead authors kept ANA staff apprised of the development of the document and sought guidance as needed. Additionally, ANA staff provided preliminary reviews of the document prior to submission to the first level of ANA review, the Committee on Nursing Practice Standards.

Responding to Reviewer Feedback

...other lead writers identified the value of reviewing scope and standards documents published by other nursing specialty organizations as exemplars. Without exception, all of the leaders of the scope and standards workgroups represented herein reported that making revisions in response to the recommendations from the ANA Committee on Nursing Practice Standards (CNPS) strengthened their respective documents. Lead writers who were members of this committee (Bickford, Finnell, and Thomas) identified the added value of this role. While recused when their respective draft specialty scope and standards document was reviewed, they identified the merits of experience in engaging in the review of other nursing specialty organization documents. Similarly, other lead writers identified the value of reviewing scope and standards documents published by other nursing specialty organizations as exemplars.

There were instances when CNPS recommendations were not accepted by the writing group. These areas of difference provided the opportunity for the writing group to make revisions in the document to further clarify member position and/or provide feedback to CNPS members explaining the rationale for not accepting the recommendation. Thus, it is important to engage in dialogue with the reviewers to ensure that the final document in fact represents the scope and standards of the nursing specialty.

Conclusion: Disseminating the Scope and Standards

Clear statements of the scope of specialty nursing practice and standards of specialty practice and professional performance help assure continued understanding and recognition of nurses’ diverse professional contributions. Thus, it is critical to inform various stakeholders of these publications. Potential strategies for dissemination include:

  1. Use social media to inform members of the specialty organization, the larger nursing community, the specialty field, and other stakeholders about the scope and standards document. This may include press releases, social media announcements, email blasts, and postings on websites. Mobile and web-based applications are another mechanism to disseminate information and provide easy and timely access to these essential documents.  
  2. Present the scope and standards document at local, national, and international conferences. Further ways to disseminate this information include the use of webinars. Attendance can be increased by providing continuing education credits.
  3. Capitalize on the use of the nursing specialty organization’s journal. This might include an announcement about the scope and standards document and how to obtain it. Journal editors can solicit manuscripts that illustrate how specialty nursing scope and standards are essential for legal, regulatory, administrative, education, and research activities.
  4. Submit articles about the scope and standards document to other specialty journals specific to the field and nursing. For example, given the prevalence of individuals with comorbid psychiatric/mental health disorders and substance use disorders, nurses in each specialty (PMHMH and addictions) should be cognizant of their respective scope and standards.
  5. Recommend the scope and standards document as required reading for nurses entering the specialty. For example, the Delaware School Nurse Comprehensive Induction Program (Delaware Department of Education, n.d.) provides each new school nurse a copy of the School Nursing: Scope and Standard of Practice (ANA/NASN, 2011). The new school nurse’s self-assessment, based on the competencies, is used to plan his/her mentoring experience. These publications can also be required as course readings by nurse educators in higher education. In addition to the foundational document, Nursing: Scope and Standards Practice (ANA, 2010b), the specialty documents are valuable to pre-licensure students seeking to learn about the various nursing specialties; registered nurses entering or engaged in the specialty practice; and to graduate nursing students as they seek additional educational preparation in a specialty nursing practice.
  6. Establish strong partnerships for marketing strategies with organizations that can promote sales of the scope and standards document. The ANA publications division will have a key role in this, yet nursing specialty organizations should also promote sale of their scope and standards documents at conferences and meetings, as well as through their website.

Nursing specialty scope and standards documents contribute to continued understanding and recognition of nursing’s diverse professional contributions. Nursing specialty scope and standards documents contribute to continued understanding and recognition of nursing’s diverse professional contributions. The goal of this article was to demystify the process leading to the publication of the nursing specialty organization’s scope and standards. We provided guidance to those considering becoming volunteer experts by reflecting on our collective experiences as lead writers of initial and revised specialty scope and practice documents. These documents are important practice resources and the invaluable to the discipline, colleagues in other disciplines, and numerous consumer groups.

Authors

Deborah S. Finnell, DNS, APRN-BC, CARN-AP, FAAN
Email: dfinnel1@jhu.edu

Dr. Finnell is Associate Professor and Director of the Master’s and the Doctor of Nursing Practice Programs at Johns Hopkins University School of Nursing in Baltimore, MD. She was the lead writer for the second edition of the Addictions Nursing: Scope and Standards of Practice. She is a current member of the American Nurses Association Committee on Nursing Practice Standards and Guidelines.

Elizabeth L. Thomas, MEd RN, NCSN, FNASN
Email: libbythomas@msn.com

Ms. Thomas is a school health consultant and developer and manager of the Delaware Comprehensive Induction Program for School Nurses. She was lead writer for School Nursing: Scope and Standards (2005 and 2011). She is a past member of the American Nurses Association Committee on Nursing Practice and Standards as well as a current member of the ANA Code of Ethics Revision Steering Committee and the chair of the ANA Nursing: Scope and Standards Revision Steering Committee.

Wendy M. Nehring, RN, PhD, FAAN, FAAIDD
Email: nehringw@etsu.edu

Dr. Nehring is Dean and Professor at East Tennessee State University College of Nursing in Johnson City, TN. She was the lead writer for the second edition of the Intellectual and Developmental Disabilities Nursing: Scope and Standards of Practice.

Kris A. McLoughlin, DNP, PMHCNS-BC, FAAN
Email: Kmcloughlin@sonnet.ucla.edu

Dr. McLaughlin is Assistant Dean, Innovative Clinical Education at University of California, Los Angeles. As of June 2015, she will be Associate Hospital Director, Colorado Mental Health Institute at Fort Logan, Denver, CO. She was the lead writer for the second edition of the Psychiatric-Mental Health Nursing: Scope and Standards of Practice.

Carol J. Bickford, PhD, RN-BC, CPHIMS, FAAN
Email: carol.bickford@ana.org

Dr. Bickford is Senior Policy Advisor in the Department of Nursing Practice and Work Environment at the American Nurses Association. In that role, she directs the specialty nursing recognition program and specialty scope and standards of practice development and review program. She provides various leadership and support services for the development and revision of specialty nursing scope and standards of practice documents.

References

American Nurses Association (ANA). (in press). Nursing: Scope and standards of practice (3rd ed). Silver Spring, MD: Nursesbooks.org.

American Nurses Association (ANA). (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Nursesbooks.org.

American Nurses Association (ANA). (2010a). Recognition of a nursing specialty, Approval of a specialty nursing scope of practice statement, and Acknowledgment of specialty nursing standards of practice. Retrieved from www.nursingworld.org/MainMenuCategories/Tools/3-S-Booklet.pdf. (under revision)

American Nurses Association (ANA). (2010b). Nursing’s social policy statement: The essence of the profession. Silver Spring, MD: Nursesbooks.org.

American Nurses Association/American Association on Intellectual and Developmental Disabilities. (ANA). (2013). Intellectual and developmental disabilities nursing: Scope and standards of practice. Silver Spring, MD: Nursesbooks.org.

American Nurses Association/International Nurses Society on Addictions. (2013). Addictions nursing: Scope and standards of nursing practice. Silver Spring, MD: Nursesbooks.org.

American Nurses Association/American Psychiatric Nurses Association/International Society of Psychiatric Mental Health Nurses. (2014). Psychiatric mental health nursing: Scope and Standards. Silver Spring, MD: Nursesbooks.org.

American Nurses Association/Correctional Nursing. (2014). Correctional nursing: Scope and standards of practice. Silver Spring, MD: Nursesbooks.org.

American Nurses Association/National Association of School Nurses. (2011). School nursing: Scope and standards of practice. Silver Spring, MD: Nursesbooks.org.

Delaware Department of Education. (n.d.). Comprehensive induction program for school nurses. Retrieved from www.doe.k12.de.us/Page/494

Suthers, L.R. (1917). The school nurse. New York, NY: G.P. Putnam’s Sons. Available here: https://books.google.com/books?id=I98HOfRxGDoC&printsec=frontcover&dq=the+school+nurse&hl=en&sa=X&ei=CtU-VaiBC47HsQScqIHYDA&ved=0CDwQ6AEwAg#v=onepage&q=the%20school%20nurse&f=false


© 2015 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2015


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