Definitions of Nursing
For many years, the nursing profession has sought to define nursing and to identify its scope of practice. It is critical that APRNs and those aspiring to this role have a clear understanding of what nursing is in order for them to provide a clear understanding of nursing’s unique contributions to quality healthcare outcomes in their interprofessional interactions. Therefore, sev- eral of the many definitions of nursing that have been put forth over the years are reviewed.
Nightingale (1859/1992) formulated one of the earliest definitions of nursing, which went beyond caring for ill patients. She emphasized the whole person, including diet and environment. The aim of nursing care, according to Nightingale, is to put the individual in the best possible con- dition so that nature can act on the person. Nightingale’s Notes on Nursing, although written 150 years ago, speaks to the substantive basis of nursing.
Not only does Nightingale elaborate on interventions nurses can employ;
she also underscores the necessity of thorough assessments before pla- nning nursing care. Reading Notes on Nursing should therefore be a part of every APRN curriculum.
In Henderson’s ( 1966 ) definition of nursing, emphasis is placed on the nurse collaborating with the individual to enhance the individual’s health status. Henderson defined "nursing” as “Assisting the individual, sick or well, in the performance of those activities contributing to health or its re- covery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as soon as possible” (p. 15).
Henderson’s definition contains many elements that constitute the sub- stantive nature of nursing. Health promotion and caring are key components of her definition. Not all individuals will recover from their diseases or injuries. It is the nurse’s role to assist the individual to achieve the goals he or she has established (Jackson, 2015 ). Henderson stresses helping the indi- vidual gain independence. Independence is a Western belief and may not be a value in all cultures. Thus, it is important for the nurse to ascertain the personal values of each individual and realize that independence may not be one of his or her preferences.
Nojima ( 1989 ), a Japanese nursing theorist, defined "nursing practice” as a “human activity carried out by nurses to help individuals organize their health conditions so that they are able to live optimally and realize their potential” (pp. 6– 7). In her definition, the focus is on a person’s quality of life. The partnership between the nurse and the individual is evident in Nojima’s definition of nursing. With the advent of globalization, it is impor- tant to review the characteristics of nursing outside of Western medicine (Nojima, Tomikana, Makabe, & Snyder, 2003).
The ANA has defined "nursing” as follows: Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, com- munities, and populations (ANA, 2010, p. 10). Previously, the definition of nursing focused on persons and their responses to health problems, rather than specific illnesses. The aforementioned definition of nursing developed in 2003, which emphasizes health promotion and optimal health, remains unchanged in current discussions of the ANA’s Social Policy Statement (ANA, 2010). The focus on health differentiates nursing from the practice of medicine.
Despite the frequent reference to the ANA definition of nursing, many APRNs have encountered difficulty practicing from a nursing model.
They have been seemingly forced to launch their practice within the medical model in part because of medical diagnoses used for billing and coding and in part because of the medical community’s and the public’s perception of APRNs. Although it is important to know the cause of a person’s pain or stress, much of nursing care remains the same despite the cause. It has been encouraging to see the Agency for Healthcare Research and Quality (AHRQ) consider problems or responses, rather than disease entities, as the focus of practice guidelines. The AHRQ web- site ( www.ahrq.gov ) is an excellent resource for EBP and current clinical practices.
Advanced practice nursing builds on the competence of the profes- sional nurse and is characterized by the integration and application of a broad range of theoretical- and evidence- based knowledge (ANA, 2010).
An APRN is defined as a “provider that is certified in one of the four roles, educated in health promotion, assessment, diagnosis, management, pharmacotherapeutics, and direct care to individuals, populations, and communities” (J. M. Stanley, 2012 , p. 244).
The APRN Consensus Model: licensure, accreditation, certification, and education (LACE) defines advanced registered nurse practice, provides a regulatory model identifying titles, roles, and population foci (APRN Consensus Workgroup & APRN Joint Dialogue Group, 2008 ). Specialization within advanced practice focuses beyond the six populations (family/
individual across life span, adult gerontology, neonatal, pediatrics, women’s health/gender- related, psychiatric/mental health) and provides depth within a population. One of the most important aspects of specialization in nursing is that the distinct specialization is always a part of the whole discipline of professional nursing (ANA, 2010).
The APRN consensus model, LACE, has stipulated that APRNs be ed- ucated within an accredited program with advanced pathophysiology, ad- vanced health assessment, advanced pharmacology; complete a minimum of 500 clinical hours; and be nationally certified. The licensure of an APRN is “defined as a legal title and credentials to be granted to all advanced prac- tice registered nurses meeting the definitional criteria. Boards of nursing are responsible for granting a second license to APRNs in all four roles”
(M. C. Stanley, 2011 , p. 248). The LACE model is relevant to improving, stan- dardizing, and regulating the scope of practice; improving the professional transition for APRNs; and highlighting safety as a motivator for national regulation (Rounds, Zych, & Mallary, 2013 ).
The ANA’s A Social Policy Statement (2010) emphasizes the characteris- tics of nursing practice to include human responses, theory application, evidence- based nursing actions, and outcomes. These characteristics build the foundation for professional nursing (ANA, 2010). Within this model, nursing’s paradigms, professional scope of practice, code of ethics, special- ization, and certification laid the base for professional nursing. Building on this base in a pyramid model are individual state’s nurse practice acts, rules, and regulations. From this level, institutional policies and procedures guide nursing practice, with self- determination as the top level of the pyr- amid model. This model lays the foundation not only for nursing paradigm, professional nursing but for all its expanded roles and specializations.
Scope of Practice
Gaining more knowledge about the substantive basis of the science of nursing is an essential component of APRN education. Scope of practice can be viewed in several ways. In fact, findings from the numerous studies undertaken to identify, describe, and classify the phenomena of concern and compassion of nurses have helped clarify our understanding of scopes of practice.
In Future of Nursing: Leading Change, Advancing Health, the IOM report (2011) emphasizes “the need for nurses to practice to the full extent of their education, achieve higher levels of education, be full partners in healthcare systems, and engage in workplace planning and policy making” (Mayo et al., 2017 , p. 72). One way to determine scope of practice from a regulatory framework is to focus on population, with each APRN working within his
or her specific practice population and his or her actual practice being de- termined by the APRN regulatory model as discussed previously. Other initiatives such as nursing diagnoses and human responses delineate the substantive basis of nursing.
Nursing Diagnoses
Nursing diagnoses are one strategy nurses have used to describe phe- nomena for which nurses provide care. Since the First Nursing Diagnosis Conference in 1973, nurses within the North American Nursing Diagnosis Association International (NANDA- I) have worked to identify, describe, and validate individual problems and concerns that fall within the domain of nursing. Currently, there are 235 approved or revised nursing diagnoses (NANDA- I, 2015). Continued efforts are necessary to identify and validate and code new diagnoses and to revise existing diagnoses. APRNs have provided and can continue to provide leadership in the nursing diagnosis movement.
NANDA- I diagnoses are grouped under nine functional patterns: exchan- ging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. According to Newman ( 1984 ), it is important for nurses to determine changes in an individual’s patterns. In approaching assessment in this manner, the focus is on the whole person rather than on specific diagnoses.
Nursing diagnoses have been widely accepted not only in the United States but also internationally (NANDA- I, 2015). As the first effort to de- velop a common language for nursing phenomena, and despite numerous criticisms, using such diagnoses assists nurses in focusing on those aspects of care for which nursing interventions can be identified and nurse- sensitive outcomes can be determined. In the United States, sev- eral projects to identify and classify nursing interventions have been ini- tiated. The National Intervention Classification (NIC) has identified and classified more than 550 research- based nursing interventions (Bulechek, Butcher, Dochterman, & Wagner, 2013 ; Johnson et al., 2005 ). To help facil- itate the value added by nursing, APRNs need to be familiar with both nursing and medical diagnoses and begin developing new models of re- imbursement beyond International Classification of Diseases , 10th revision ( ICD- 10 ) codes.
Human Responses
Human experiences and responses proposed by the ANA (2010) include promotion of health and wellness; promotion of safety and quality of care; care and self- care processes, and care coordination; physical, emotional, and spiritual comfort, discomfort, and pain; adaption to physiologic and pathophysiologic processes; emotions related to the ex- perience of birth, growth and development, health, illness, disease, and death; meanings ascribed to health and illness; linguistic and cultural sensitivity; health literacy; decision making and the ability to make
choices; relationships, role performance, and change processes within relationships; social policies and their effects on health; healthcare sys- tems and their relationships to access, cost, and quality of healthcare;
and the environment and the prevention of disease and injury.
As with nursing diagnoses, these identified human responses assist APRNs in focusing on the health concerns and needs of the individual, population, or communities. Advanced practice nursing care is of primary importance in producing positive individual outcomes while focusing on health promotion, disease management, education, and wellness.
Therapeutics for managing the human responses or assisting the person in managing them may transcend medical care. For example, despite var- ious causes of sleep problems, nursing interventions, such as massage and music therapy, can be used successfully. Viewing nursing in the context of and the perspective of human responses helps all nurses organize the patient- centered plan of care with the nurse’s point of view.