Standards of care in nursing are guidelines that provide a foundation as to how a nurse should act and what they should and should not do in their professional capacity. These guidelines establish a baseline of quality patient care and provide an objective standard of accountability within the profession. Standards of care are enforced by courts of law and state Boards of Nursing, who evaluate a nurse’s practice against these standards. If a nurse’s actions (or lack of actions) do not meet the accepted standard of care, their conduct may be found to be negligent.^[1]

Standards for nursing care are set by several organizations, including the American Nurses Association (ANA), states’ Nurse Practice Acts, agency policies and procedures, federal regulators, and professional nursing organizations.

American Nursing Association’s Scope and Standards of Practice

In the United States, the American Nurses Association (ANA) publishes two resources that set standards and guide professional nursing practice: Code of Ethics for Nurses and Nursing: Scope and Standards of Practice. The Code of Ethics for Nurses establishes an ethical framework for nursing practice across all roles, levels, and settings.^[2] It is discussed in greater detail in the “Ethical Principles” section of this chapter. Nursing: Scope and Standards of Practice describes a professional nurse’s scope of practice and defines the who, what, where, when, why, and how of nursing. It also sets 18 standards of professional practice that all registered nurses are expected to perform competently.^[3]

The ANA’s Standards of Professional Nursing Practice are “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.”^[4] These standards define a competent level of nursing practice based on the critical thinking model known as the nursing process and include the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.^[5] Each of these standards is further discussed in the “Application of the Nursing Process in Mental Health Care” chapter of this book.

The ANA’s Standards of Professional Performance are 12 additional standards that describe a nurse’s professional behavior, including activities related to ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship, and environmental health. All registered nurses are expected to engage in these professional role activities based on their level of education, position, and role. Registered nurses are accountable for their professional behaviors to themselves, health care consumers, peers, and ultimately to society.^[6] The Standards of Professional Performance are as follows^[7]:

• Ethics. The registered nurse integrates ethics in all aspects of practice.
• Advocacy. The registered nurse demonstrates advocacy in all roles and settings.
• Respectful and Equitable Practice. The registered nurse practices with cultural humility and inclusiveness.
• Communication. The registered nurse communicates effectively in all areas of professional practice.
• Collaboration. The registered nurse collaborates with the health care consumer and other key stakeholders.
• Leadership. The registered nurse leads within the profession and practice setting.
• Education. The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking.
• Scholarly Inquiry. The registered nurse integrates scholarship, evidence, and research findings into practice.
• Quality of Practice. The registered nurse contributes to quality nursing practice.
• Professional Practice Evaluation. The registered nurse evaluates one’s own and others’ nursing practice.
• Resource Stewardship. The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and judiciously used.
• Environmental Health. The registered nurse practices in a manner that advances environmental safety and health.

American Psychiatric Nurses Association Standards of Practice

In addition to the ANA Standards of Professional Nursing Practice, the American Psychiatric Nurses Association establishes standards of practice for psychiatric-mental health nurse specialists in Psychiatric-Mental Health Nursing: Scope and Standards of Practice.^[8] These standards are built on the ANA’s Standards of Professional Nursing Practice, with additional activities included under the Intervention standard of care. These interventions are further discussed in the “Application of the Nursing Process in Mental Health Care” chapter.

Nurse Practice Act

In addition to the professional standards of practice, nurses must legally follow regulations set by the Nurse Practice Act and enforced by the Board of Nursing in the state where they are employed. The Board of Nursing is the state-specific licensing and regulatory body that sets standards for safe nursing care and issues nursing licenses to qualified candidates, based on the Nurse Practice Act enacted by that state’s legislature. The Nurse Practice Act establishes regulations for nursing practice within that state and defines the scope of nursing practice. If nurses do not follow the standards and scope of practice set forth by the Nurse Practice Act, they can have their nursing license revoked by the Board of Nursing.

Nursing students are legally accountable for the quality of care they provide to patients just as nurses are accountable. Students are expected to recognize the limits of their knowledge and experience and appropriately alert individuals in authority regarding situations that are beyond their competency. A violation of the standards of practice constitutes unprofessional conduct and can result in the Board of Nursing denying a license to a nursing graduate.

Employer Policies, Procedures, and Protocols

In addition to following professional nursing standards and the state Nurse Practice Act, nurses and nursing students must also practice according to agency policies, procedures, and protocols. For example, each agency has specific policies regarding the use of restraints. If a nurse did not follow this policy and a patient was injured or died, the nurse could be held liable in a court of law.

Agencies also have their own sets of procedures and protocols. For example, each agency has specific procedural steps for performing nursing skills, such as inserting urinary catheters. Agencies also have protocols that are precisely written plans for a regimen of therapy. For example, agencies typically have a hypoglycemia protocol that nurses automatically implement when a patient’s blood sugar falls below a specific number and includes actions such as providing orange juice and rechecking the blood sugar. These agency-specific policies, procedures, and protocols supersede the information taught in nursing school, and nurses and nursing students can be held legally liable if they don’t follow them. Therefore, it is vital for nurses and nursing students to review and follow current agency-specific procedures, policies, and protocols when providing patient care.

Federal Regulations

In addition to professional standards, state Nurse Practice Acts, and employer policies, procedures, and protocols, nursing practice is also influenced by federal regulations enacted by government agencies such as The Joint Commission and the Centers for Medicare and Medicaid.

The Joint Commission (TJC) is a national organization that accredits and certifies over 20,000 health care organizations in the United States. The mission of The Joint Commission is to continuously improve health care by setting standards for providing safe, high-quality health care. The Centers for Medicare & Medicaid Services (CMS) enforces quality standards in health care organizations that receive Medicare and Medicaid funding. Nurses must follow standards set by these agencies and implemented by their employers. For example, the expectation that a nurse checks medication rights three times before administering medication to a patient is based on a federal regulation.