Nursing_Fundamentals_Catalogue

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| Empowering Knowledge 8
Learningoutcomes
Mastery of contentwill enable you to:
•understand the value of using a reflective and systematic approach
to clinical reasoning
•discuss theways inwhich a systematic approach to clinical
reasoning enhances nursing knowledge and skilldevelopment
•discuss theways inwhich nursing knowledge and skill
development enhances the process of clinical reasoning
•explain how using a systematic approach to clinical reasoning
contributes to the visibility of nursing practice
•explain the relationship between critical thinking and clinical
reasoningwithin nursing practice
•discuss the sixbasic domains evidentwithin all processes of
clinical reasoning
•use criticalquestioningwithin each of the six basic domains of the
clinical reasoning process.
Information/data,
p. 51
Judgements and
decisions,p. 51
Nursing knowledge,
p. 52
Nursingmodels,
p. 47
Outcomes,p. 49
Reasoningprocess,
p. 49
KEYTERMS
Actionplanning,
p. 51
Clinical reasoning
cycle,p. 50
Clinical reasoning
models,p. 47
Cognitivebias,
p. 47
Criticalquestions,
p. 56
Critical thinking,
p. 49
Goals andpriorities,
p. 50
ClintDouglas and JackieCrisp
Developing clinical
reasoning for nursing
practice 4 CHAPTER
Discover More
TEXT FEATURES
Each chapter is structured with:
Learning outcomes
CHAPTER 22 Working With dying, death and grief 523
thegriever.A listof localpsychologistsorcounsellorswho
are skilled in bereavement support can be an invaluable
resource,as cananafter-hours telephone supportnumber
or liaisonpersons in thegriever’s community.
CLINICALREASONINGPROCESS
Grieving isanatural response toa lossand isconsidered tobe
abeneficialcopingprocess. It isalsoa reactiveprocessandhas
therapeuticvalue.Grieving ishealthyandenables thebereaved
to reflectonandaccept the realityof the loss.Thenursemust
feelconfident toassess the situationcriticallyandmakean
initialneedsanalysis.Theoverallgoalofnursingassessment
is togather relevant informationanddata inorder togaina
totalviewof theclient’shealthandpsychosocial
carefullyexploring informationgained from inte d
collating thedata inapreciseandmethodicalw riate
judgementsanddecisionscanbemade toworkwith theclient
in theirgrievingprocess.Assessmentprovidesanopportunity
for thenurse toexplorewith theclient information relating to
perceivedandactualpriorityproblems (mentalandphysical).
MAKINGAPPROPRIATE JUDGEMENTSAND
DECISIONS
Verbalandnon-verbalcommunication techniquescan
encourage freeflowof informationandprovidemeaningful
data forevaluation (seeChapter12).These include listening,
reflecting,clarifying,usingnon-verbalcues,appropriateuseof
silence, sharingperceptions,confrontingcontradictionsand
reviewing thediscussions.
Cultureanddevelopmentalconsiderationsare two factors that
influencecommunication.Culturehasaprofoundeffecton the
waypeoplecommunicateandbehave. It is therefore important
tokeep inmind thatculturaldifferencesmay influencehow
verbalandnon-verbalmessagesare interpreted.Forexample, in
manySouth-EastAsiancultures–ofwhich thereare significant
immigrantpopulations inbothAustraliaandNewZealand–
manywomenavoideyecontactwithmen.Conversely,many
Westernwomen lookdirectlyat theperson towhom theyare
talking. Ageordevelopmental levelcanalsoaffect theway the
assessment ishandled,especially if theclient isveryyoungor
veryold. In theyoung,communicationdependson thechild’s
cognitivematurity,asnotedabove. In theelderly,consideration
mustbegiven to theextent towhich thememoryand sensory
functionmaybeaffectedby theageingprocess.Thereare times
whenboth theyoungand theelderly, inparticular,arehesitant
to sharepersonal information,anddevelopingcommunication
skills thatmaximise thepossibilityofopencommunication isa
priority for studentnurses.
Duringperiodsof lossoranticipated loss,aclient’semotions
andbehavioursmaybe ina stateofflux.Thismakesassessment
all themorechallenging.Nurses shouldnotassume they
knowhowaclientor familymemberswill react.Continual
assessment isessential if supportand/or interventionsare tobe
compatiblewith theircurrentneeds.Assessmentof theclient
and familybeginsbyexploring themeaningof the loss to the
people involved.Examplesof topics tobeexplored include the
survivor’smodelof theworld,personalcharacteristics suchas
personality,values, thenatureof family relationships, support
systems,natureof loss,culturaland spiritualbeliefs, lossof
personal lifegoals,hope,phaseofgrief, risksandnursing role
perceptions.
When interviewing theclientand family, it is important thatan
honestandempatheticapproach is taken.Bemindfulof setting
the toneanddirectionof the interview,andofestablishing
amutualunderstandingof thepurposeof theexchange. In
the initialphase it is important toestablish rapport,ensure
acomfortableandnon-threatening settingandclarify the
expectationsorgoalsof the interview.
Establishing rapport
Establishing trustand rapport isachallengingprocess,
particularlygiven theculturaldiversityofAustralianandNew
Zealandpopulations.Acleardemonstrationof respect for the
clientandanacceptanceof theclient’suniquenessasaperson
facilitate rapport.Greet theclientbynameand introduce
yourself. It isusualpracticenot touse theclient’sfirstname
unless invited todo so. InAustralasian society,offering to shake
hands isoneway todemonstrate sincerityandacceptance.
Non-verbalbehaviours
Non-verbalbehaviours shouldmatch theverbalmessages.
Appropriateand sensitiveeyecontactandnon-intimidating
positioning shouldbeused.Sincereandopeneyecontact
(except incertaincultures/circumstances) isoftenvitalwith
avulnerableperson,asnormalcontactwithothersmaybe
disruptedby theemotionsgenerated fromcircumstances
surrounding thedeath.Positionyourself so thatyouare facing
theclient. If theclient is seated, sitata slightangleoppositebut
facing,withanappropriatedistancebetween.Avoidnon-verbal
behaviours suchas frowningoryawning,orexpressionsof
impatienceorboredom,which implya lackof interest.When
beginning the interview, itmaybeappropriate to startwith
abriefbutcasualconversation thathelps theclient relax.
Client-focusedcasualconversationmayhelpalleviateany
awkwardness theclientmay feel in talking toa stranger in the
healthcare setting.Casualconversationcanalsobea sourceof
valuable information.
Ensuringcomfort
Ensure that theexchangeof information takesplace inaprivate
setting free from interruptionsanddistractions. It is important
toclarify that theclient is feelingup to the interviewbefore
starting.Verbal therapeuticcommunication techniques involve
open-endedquestions thatgive theclienta senseofcontrol
over theprocess– forexample, ‘Tellmeaboutyour family’,
‘Howareyou feelingnow?’or ‘Whatcanyou tellmeaboutyour
relationshipwithX?’
Definingexpectations
At thebeginningofany interaction it is important toclarifywhat
both thenurseand theclientexpect from theexchange.Make
itclear thatany informationexchangedwillbe treatedwith
sensitivityand respect.This isespecially important inAustralian
Indigenousculturewhere theabusesof thepastcontinue to
have impactsonestablishing trust in services (seeChapter14).
During theassessmentphase, it is important to focusonhow
theclient is reacting,notonhowyoubelieve they shouldbe
reacting.Give specialattention togrief-relatedbehaviours
displayedby theclient,andpaycarefulattention to theclient’s
experienceand the tasksofgrief thatmaybe left incomplete,
whichmay threaten theclient’spsychologicalorphysical
Clinical reasoning
process
PART 4 ADAPTING NURSING: PEOPLE, CONTEXT AND CULTURE
266
awareness of themselves as cultural beings. Further, all
healthprofessionalsneed toconsiderhowculture,classand
socialmarginality impactonbothhealthandhealthcare. In
the following sectionswewill show that social responses to
clients’class,ethnicity,genderorabilities influencepeople’s
lifechancesandhealth.Suchconcernsare intimatelyrelated
to the social determinants of health, that is, to factors
beyond the controlandbehavioursof come
to gripswith these complex issuesw now
to themodel of cultural safety and d ly the
specific conceptualisation of culture that underlies the
modeland its focuson the socialdeterminantsofhealth.
Cultural safety
Cultural safety(kawa whakaruruhau) was developed
within theMāori community in the 1990s byMāorinurse
scholarIrahapetiRamsden inAotearoaNewZealand(1993,
2002).Ramsdenandcolleaguesdeveloped themodelpartly
in response to a first-yearMāori nursing student’s astute
comment: ‘Youpeople talk about legal safety, ethical safety,
safety in clinical practice and a safe knowledge base, but
whataboutculturalsafety?’(Ramsden2002:1).TheseMāori
nursing students alerted Ramsden to the expectations
they felt to conform to the dominant institutional culture
and their experience of non-Māori ‘experts’ lecturing to
them about traditionalMāori culture.Their experiences
suggested that there was only one correct, authentic way
of beingMāori, which, as urbanMāori whose ancestors
experienced thedisruptionsofcolonisation, theycouldnot
embrace.
Cultural safety therefore aimed for cultural change
by exposing and addressing such power imbalances to
decrease the impact of cultural dominance and racism in
health care, education and research (McCleland 2011).
Ramsden also saw that nursing curricula were devoid
of structural issues and were designed by and for those
who did not share her cultural position or experience of
colonisation. She challenged this cultural dominance,
particularly theway it shapedpolicyanddevelopednurses
asmerebiomedical techniciansrather thanagentsofsocial
change (Ramsden 2002).Ramsden saw cultural safety as
away for nurses to consider how their socialisation and
cultural position impacted on their work, emphasising
the links between ill-health and
status and political agendas.
approach contrastswith individ
that illnessesmerelyoccur ‘withinbodies’.
Underpinnedbycriticalsocialtheory,culturalsafetyalso
recognises thatnursingcare,educationandresearcharenot
value neutral activities but reflect socio-political contexts
and thevalues,assumptionsandprioritiesof those involved
(Ramsden 2002, Reimer-Kirkham et al 2009). Cultural
safety focusesonhow people are treated in society,nothow
theyareculturallydifferent .That is, the importofdiversity is
turnedon itshead incultural safety,as it is social responses
to diversity that create health impacts not the existence of
the diversity itself (Cox& Simpson 2015). Consequently,
cultural safety is about power – personal, professional
and institutional power in health services, and the impact
on thosewho use the service; the peoplewho define the
CLINICAL EXAMPLE
An exampleofbeing culturally unsafe
MrsG is anAboriginalwoman in her 40swho goes to the
hospital in the rural townwhere she lives at about11.45 am
on aMondaymorning, to see a doctor.She has pains in
the stomach that have kept her awake all night and got
worse after breakfast.She is accompanied by a female
cousin,MrsS,who is some years younger.Although only
in her 40s,MrsG is a respected elder in her community, a
fact that reflects the statistically reduced life expectancy of
Aboriginal people.
MrsG is told by the young female nurse at the front desk
to take a seat in the sparse basicwaiting room. There are
nomagazines, television or tea-making facilities here, such
as onemight find in city 1.00 pm no one has
come to seeMrsG and en offered somuch as
a drink ofwater.
Feeling frustrated andworried aboutMrsG,MrsS finally
finds the courage to confront the nurse and askswhen the
doctorwill be there to seeMrsG.
The nurse responds by saying, ‘Doctor is on his lunch
break.’She then says toMrsS, ‘Are you a drinker too,
love?’At thisMrsG gets up and says to her cousin, ‘Let’s
go along’, and they leave the hospitalwithout being seen.
MrsG still has abdominal pain and bothwomen are angry
at being referred to as ‘drinkers’, especially as both are
teetotallers and devoutChristians.
Lessons to be learnt from this example are:
• the clientswere culturally unsafe – theywere
demeaned,diminished and disempowered
• the nurse and the hospital neglected their duty of care
• the nurse has unexamined prejudices towards
Aboriginal people and operates on stereotypes
• the use of the term ‘love’ from a youngwhitewoman
was offensive to such respected leaders in the
lients to health serviceswas limited by
h-time policy
• itmay take years for eitherwoman or their large
extended families to seek help from the hospital again.
Cox L2007 Fear, trust andAborigines: the historical experience of state
institutions and current encounters in the health system,Health andHistory
9(2):70–92.Reproducedwith permission. Clinical examples
CHAPTER 3Engaging patiEnts and kEEping thEm safE 33
in decision-making about the care they receive. A
meaningful relationship with the patient enables you as
thenurse tomake sound clinical decisions that are based
on thepatient’sbest interests.
safety as one of the
fundamentals of care
Patient safety was of central concern to Florence
Nightingale as reflected in her quote, ‘the very first
requirement in a hospital is that it should do the sick no
harm’ (Nightingale1859).Safetycontinues tobeaconcern
for many modern healthcare systems, with evidence
suggesting thatNightingale’sdoctrineof ‘doingnoharm’ is
notbeing completely followed.The InstituteofMedicine’s
(IOM) landmark publication Crossing theQualityChasm
(2001), for example, argued that theUShealthcare system
was failing todeliverconsistent,high-qualitymedicalcare,
with such care instead frequently harming or injuring
patients. The IOM called for fundamental changes to
21st-centuryhealthcare systems to ensure the safetyof all
patients.
In this part of the chapter, we consider how the
Fundamentals of Care Framework helps you to address
patient safety concerns when providing care. As can
be seen from Figure 3-1, safety is conceptualised as a
fundamentalof care, alongwithother fundamentals such
asnutrition,hydrationandelimination.Thenurse–patient
relationship is central to ensuring this fundamental need
is appropriately met. While policy and organisational
structures focusingon safetyundoubtedlyhave an impact
on the ability of nurses to deliver safe and effective care,
our focus in this chapter ison equipping you as a student
and beginning nurse with the skills to operate in a safe
manner.That is, to ensure patient safety becomes part of
yourpersonal andprofessional responsibility as anurse.
Patient safety encompasses three interrelated
elements: physical, psychosocial and environmental
the intersectionof thesedifferent typesof safety
tient’spersonalsafety (seeFigure3-2). It isonly
h of these types of safety are appropriatelymet
that patients can be considered safe. Ensuring patients’
personal safety requires nurses to embed patients’ needs
in their thinking, reflection and assessment processes
(Kitson et al 2014). Careful assessment and planning
prior toany interventionor interactionwithapatientwill
ensure that injury and harm do not occur and that any
safetyrisksare reduced.
Research focus
developing apositive relationshipwithpatients is known
tobe important for thedeliveryof high-quality care.this
paper sought to identify the factors that contribute to the
developmentof a caring relationshipbetween thenurse
andpatient.
Researchabstract
the study involved conducting an umbrella review.
Umbrella reviewsbring together evidence from existing
systematic reviews inorder to synthesise the available
evidenceon aparticular topic.thisumbrella review
looked at studies examiningpatients’ andnurses’
perspectivesonwhat is important in the nurse–patient
relationship.theumbrella review identified six key areas
that are associatedwithdeveloping andmaintaining
caring,positive nurse–patient relationships.they are:
• nurses’ andpatients’ expectationsof the relationship
• nurses’ values andbeliefs (e.g. their thoughts,
perceptions, attitudes and associatedbehaviours)
• nurses’ knowledge and skills (both clinical skills and
supportbehaviours)
• nurses’ ability to communicate effectively in a variety
ofways
• how thephysical and social contexts inwhich care is
takingplace affect thenurse–patient relationship
• the impactof the relationshiponpatients/families,
nurses and nursing students.
Evidence-basedpractice
• the nurse–patient relationship shouldbebasedon
nursing’s inbuilt values such as trust, sympathy,
support and responsibility, and these values should
be reflected in the attitudes andbehavioursof
nurses.
• Compassionate care and technical skill are equally
important indeveloping andmaintaining the
nurse–patient relationship.
• nurses need to consider the context inwhich they
areproviding care andhow thismight impact the
nurse–patient relationship.
• the nurse–patient relationship notonly has an
impactonpatients and families/carers,buton
nurses aswell.nurses findgreat reward in a
positive relationshipwith theirpatientsbut can also
experienceguilt and frustrationwhen agoodquality
nurse–patient relationship is not achieved.
Reference
WiechulaR et al 2015Umbrella reviewof the evidence:
What factors influence the caring relationship
between anurse andpatient? Journalofadvanced
nursing,doi:10.111/jan.12862.
RESEARCH HIGHLIGHT Research highlights
CHAPTER 9 Examining thE Ethical practicE of nursing 149
of ‘characterological excellence’ in determining ethical
conduct (Oakley 2006, Van Hooft 2014).This is made
manifest by the expression of suchmoral virtues as care,
compassion, kindness, empathy, sympathy, altruism,
generosity, respectfulness, trustworthiness, personal
integrity, wisdom, courage and fairness.Virtue theorists
claim that without the characterological excellence of
virtue, ‘a person could, robot-like, obey everymoral rule
and lead the perfectlymoral life’, but in doing sowould
be actingmore like ‘a perfectly programmed computer’
than amorally responsible human being (Pence 1991).
There isa sense inwhichbeingmoral involvesmuchmore
thanmerely following rules; themissing link, claimvirtue
theorists, is thispoint,Pence (1991)writes:
we need h more about the outer shell of
behaviou h judgments, that is, we need to
know what kind of person is involved, how the person
thinks of other people, how he or she thinks of his or her
owncharacter,how theperson feelsaboutpastactions,and
alsohow theperson feelsabout theactionsnotdone.
Virtue ethicsis particularly relevant to nursing and to
nursing ethics since virtuous conduct is intricately linked
to therapeutic healing behaviours and the promotion of
humanhealth andwellbeing.
The nursing profession’swell-articulated ethic of care
(regardedbymany influentialnurse theoristsas themoral
foundation, essence, ideal and imperative of nursing) is
consistent with a virtue theory of ethics (see the classic
works of the following nurse theorists:Benner&Wrubel
1989,Gaut 1991,Gaut&Leininger 1991,Leininger 1988,
1990, Roach 1987,Watson 1985a, 1985b). Significantly,
virtue ethics is enjoying a renaissance in the nursing
ethics literature – particularly in regard to the issue of
caring forvulnerableandmarginalisedgroupsofpeopleat
risk of being treated as ‘different’ by healthcare providers
(Armstrong2006,2007).
cross-cultural ethics
As highlighted by the ‘Mr G’ case discussed on p. 139,
anotherperspectiveon ethics andbioethics thatwarrants
considerationbynurses is cross-cultural ethics.Thebasic
assumptions of cross-cultural ethicsreflect the views
that:
n ethics isverymuch aproductof the culture, society
andhistory fromwhich ithas emerged
n all cultureshave amoral system,butwhat this
system is andhow it is appliedwillvary across, and
sometimes evenwithin,different cultures
n there isno such thing as auniversal ethic; that is,one
ultimate standardofmoral conductwhich applies
to allpeople equally regardlessof their individual
circumstances, context and culture– inotherwords,
a ‘one sizefits all’ approach to ethics (Johnstone2012,
2016).
In any culturally diverse society it is imperative that a
culturally informed,knowledgeableand sensitiveapproach
to health care is taken (Johnstone 2012, Johnstone &
Kanitsaki 2008). One reason for this is that a failure to
adopt such an approach can result in otherwise serious
moral harm being caused to people.Cross-cultural ethics,
therefore,goesfarbeyondmerelyconsideringandcritiquing
the nature and content of mainstream ethical theories;
it also involves a systematic examination of the moral
implicationsofculturaland linguisticdiversity inhealthcare
domains; for example, the extent towhichpatientsofnon-
English-speaking and diverse cultural backgrounds suffer
unnecessarily on account of the cultural and language
differencesbetween themand theirprofessionalcarers (see
deBruijneetal2013,Divietal2007, Johnstone&Kanitsaki
2006,2009a,Suurmondetal2010).
Nurses and other healthcareworkers have a stringent
moralresponsibility toavoidand/orprevent theotherwise
avoidable moral harms that can result from a failure
to take into account the language and cultural needs of
theirpatients (Johnstone&Kanitsaki 2006, 2008, 2009a).
The harmful aftermath of racism in health care is a
particular example of this.Racism in nursing and health
care is a problem that has not been formally recognised
as an important ethical professional issue (Johnstone
& Kanitsaki 2009b, 2010). A cross-cultural approach
to ethics would not only help identify the existence
of racism in nursing and healthcare contexts, but also
guide an effective response for dealingwith it and, if not
successful in eradicating it, at leastminimise its harmful
consequences topatienthealth.
WORKING WITH DIVERSITY
Truth-telling around cancer and other life-limiting diagnoses
stands as one of the most controversial issues in cross-
cultural health care. Research has shown that truth-telling
is not just an issue for people fromGreek backgrounds, but
also for people from other traditional cultural backgrounds
(e.g. Iranian, Pakistani, Japanese, Italian, Korean,Chinese).
In these cases, truth-telling about a diagnosis of serious
life-limiting illnesses (especially cancer-related illnesses) is
regardedasharmful, ‘undesirable’andhence tobeavoided–
most notably on the grounds that it could undermine the ill
lovedone’shopeand thewill to live (Johnstone2012,2016).
Problems most commonly arise in situations where the
healthcare provider (e.g. doctor, nurse) does not share the
same cultural background as the patient and family,whose
cultural world views are unfamiliar and even confronting to
them andwhich they do not understand.
PART 1 EVOLVING NURSING: NURSING AND THE HEALTHCARE ENVIRONMENT
8
Nursing’s contribution to these three elements is greater
than any other health profession.The nursingworkforce
is the single largest clinical workforce with the most
direct clinical care time.Nurses continue to provide care
with resilience and versatility, while often withminimal
resources and organisational support.Nursing can be, as
the International Council of Nurses (ICN 2015) states,
‘a force for change’.Unfortunately, reform may have short-term goals,
including immediate funding reductions. As the largest
workforce and, therefore, the highest cost burden, the
nursingworkforce isoften cut, leaving fewerpeople todo
morework. Research shows that RN staffing levels have
direct implications for patient care. It demonstrates that
hospitalswith a higher ratio of degree-preparedRNs-to-
patients have lower mortality rates (Aiken et al 2014).
Hospitals with lower RN staffing numbers are linked to
an increasednumberof adverse events including falls and
medication errors (Duffield et al 2014). As a result, the
aimsofhealthcare reform arenot realised.
The escalating costs of health care require that
measuresbe taken to contain costs to levels that countries
can afford and sustain.Thesepressureshighlight theneed
for how resources in health care, particularly nursing,
can be used to their optimal level. When the nursing
profession is optimised, evidence demonstrates that the
quality of health service provision improves.When the
qualityof services improve, resourcesareoftenusedmore
efficiently. For example, an optimised and appropriately
resourcednursingworkforce is linked to reduced adverse
events (asmentioned above), improved health literacy of
patients, reduced length of stay, decreased readmission
rates, improved hospital avoidance and better patient
outcomes (Aitken2014).As such, the threeaimsofhealth
reform canbe achieved.
• CRITICALREFLECTION POINT
Whywould supportingRNs towork to their full scope
ofpracticecreateamoreefficienthealth system?How
important ishealth literacy to the futureofhealthcare
provisionandhowcannursingcontribute to improving
health literacy?
Nursing leadership and
healthcare reform
The nursing profession is uniquely placed to lead
healthcare reform. Nurses have close interaction with
patients and their families in all health settings across
the health continuum. They can help interpret and
understand people’s needs and expectations for health
care.Theyareactively involved indecision-makingwithin
the clinical team and inmanagement.They do thiswith
a foundation of care informed by research and evidence.
This understanding, experience and proximity to the
patients’ needs are critical components of what nursing
canbring to the table andhow it can enable reform.
As such, nurses have an important contribution
to make in health service planning, management and
policy setting. Nurses must contribute to public policy
development throughmanagement and leadership roles
at all levels andwithdirect engagementwith theirprofes-
sionalorganisations.Toachieve this levelof responsibility,
itcannotbeassumed that itwillautomaticallybeprovided
to the profession.Historically, inmany instances, nurses
have been left out of the decision-making process and
have been leftwith implementing an initiative or policy
thathasnotbeenwell informed.The roleof theprofession
therefore must be proactive to maintain this level of
influence and involvement.
Just as important as the planning and policy setting,
nursesneed tobe leaders inhealthcaremanagement.The
InternationalCouncilofNurses(2015)assertsthatnursing
servicesmust be directlymanaged by nurses.The reason
for this is that the professionmust be responsible for the
professionalpractice ofnursing.Noprofession outside of
nursing iswell positioned enough to be held to account
and to lead the scope of practice and the standards for
practiceof theRN.
• CRITICALREFLECTION POINT
Thinkabouta recenthealth issuediscussed in thenews.
Didnursinghavea voice?Howdo you thinknursescan
promote their stories, insights, researchandexpert
opinions via socialmedia?
Regulation of the nursing
profession
TheNursing andMidwifery Board ofAustralia (NMBA)
and Nursing Council of New Zealand are responsible
for professional regulationand setting standards, codes
and guidelines for thenursing andmidwiferyprofessions
(Box 1-2).The role of professional colleges and associa-
tions in developing specific standards of practice and
credentialling individual nurses is increasing. RNs are
individuallyaccountable for theirownpracticeandhavea
personal responsibility tomaintain their competency and
meet professional standards in order to maintain their
licence to practise.The role of theRN has evolved along
with changes in advancing technology, newly defined
patient needs and changes to the way health care is
delivered. In thisway, it isnotunreasonable to expect that
the roleof theRNwill continue to evolve and change. It is
Working with diversity
Critical reflection points
Key terms