Notes on Core Competencies, Evidence-Based Practice, and Professional Standards (Box 1.2–1.3)

Box 1.2 Core Competencies for Health Professionals

• Provide patient-centered care
• Work in interdisciplinary teams
• Employ evidence-based practice
• Apply quality improvement
• Utilize informatics

Beyond the basic education, competent practice requires ongoing learning, continuing education, and continued competency. These attributes are crucial to safe, effective, and ethical professional practice.

• Ongoing improvement and knowledge are the goals of continuing education, which is required for relicensure in some states and recertification in specialty areas.
• Continuing education involves more than obtaining required credits, in-service hours, and formal degrees. Remaining current with ideas presented in the nursing and scientific literature is important to incorporate evidence-based information into practice and to focus on health equity for all.
• The Internet has made staying current more convenient, but you should evaluate the source and its validity (organization/agency vs. social media/personal perspective).
• Identifying your own learning and developmental needs is an expectation and a continual process for competent professional practice. In essence, continuing education for competency involves self-assessment, ongoing learning, and self-evaluation. The focus is on discovery, as in baccalaureate and graduate education.
• Ongoing learning means your mind is challenged daily with new ideas, building on a professional knowledge base and skills. Opportunities for continuing education abound through formal programs, professional journals, and online resources.
• Many professional organizations offer online services for members (reviews of current literature and care products, continuing education programs, forums). Publishers provide online resources with discounts, e-mail updates, associated websites, discussion groups, and interactive CE offerings.
• The ongoing challenge is developing new knowledge, and it is the professional's responsibility to maintain currency for the specific practice area and to document their progress.

Evidence-Based Practice and Research

• Nursing research is more than leading/participating in a study. The core competency is evidence-based practice and research to guide practice.
• Greiner and Knebel (2003) define evidence-based practice as the integration of the best research with clinical expertise and the patient's values for optimal care, as well as participation in learning and research activities ($pp. 45-46$).
• In interpretive statements of the Code for Nurses, "All nurses must participate in the advancement of the profession through the knowledge development, evaluation, dissemination, and application to practice" (ANA, 2015, $p. 27$).
• In the revised standard of professional performance, "scholarly inquiry requires that the registered nurse integrates scholarship, evidence, and research findings into practice" (ANA, 2021, $p. 100$). This standard includes:
  • identification of researchable questions,
  • using findings,
  • sharing knowledge with others,
  • participating in an investigation,
  • protecting human subjects,
  • and searching the literature for demonstrated innovations in practice.
• Evidence-based practice adds to the knowledge base, enhances practice, promotes improved outcomes for patients, and fosters practice based on evidence of efficacy rather than tradition or trial and error. Collaboration with others and sharing new knowledge are critical. Chapter 5 will focus further on EBP and research.

Quality of Practice

• The effectiveness of nursing care to address appropriate, equitable, and measurable patient outcomes is an expectation of the professional nurse.
• Improvement in the quality of practice is a core competency of all health professionals. Quality improvement involves more than judging whether a nursing intervention was appropriate; it also asks how to refine practice based on current evidence and documented evidence of practice effectiveness with efforts on healthcare equity.
• Quality improvement goals: efficacy, equity, and efficiency. Efficacy in meeting patient outcomes is not sufficient by itself; activities must also be acceptable for the patient population and align with metaparadigm concepts of human beings, health, environment, and nursing. The patient is the focus; equity and efficiency are vital to preserve resources (personal energy and material/physical resources).
• A central question: how can practice be made safer, more effective, and equitable? This can lead to innovative and changed practices for improved patient outcomes, considering human needs, environment, the concept of health, and care technologies.
• Healthcare equity is defined as "the state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance" ($NASEM, 2017, p. 32$).
• The ongoing focus is on safer, more effective, and equitable practice, with attention to equity in health outcomes and resource use.

Communication

• Effective communication has long been a focus and hallmark of professional nursing and requires constant reevaluation in different situations and with different individuals.
• Communication is more than a verbal encounter; it is an interaction involving interpersonal and cultural facets. Messages must be communicated into the plan of care, documented appropriately, shared through multiple channels and media, and lead to quality improvements for equitable care.
• Dissent, debate, conflict, and negotiation are natural outcomes and should focus on quality and equitable healthcare.
• Consider evolving technologies, such as telehealth, where patients and providers interact at a distance.
• Effective communication skills are continually refined by the professional nurse who leads the team to achieve quality patient outcomes. Chapter 6 covers refinement of interpersonal and professional communication.

Leadership

• Leadership is an expectation for the professional nurse, both in the practice setting and in the profession.
• Nurses must project a positive image and the vision/actions needed for effective patient outcomes daily, in an effective working environment.
• Leadership involves managing care effectively and leading others; it is a commitment to patients, colleagues, and the profession.
• Leadership extends beyond the care environment to involvement in the institution or agency (e.g., shared governance or committee involvement) and in the profession at large.
• Nurses also assume leadership in the community through service activities using their knowledge, skills, and abilities. They lead health-promoting activities in employment, professional community, and among family and friends, and residents often know which nurses in the area to approach for health issues.
• Nurses engage in healthcare policy and changes needed for health equity and improved community outcomes.

Collaboration

• Collaboration is required in all standards of professional performance and includes the healthcare consumer and other key stakeholders in nursing practice (ANA, 2021, $p. 95$).
• Professional interactions should be ethical, equitable, and patient-centered, based on information and needs of colleagues who influence patients and on the quality of practice.
• Interprofessional collaboration requires excellent communication and leadership skills focused on effective practice and quality outcomes.
• The healthcare team is patient-centered and aims for positive outcomes; outcomes do not arise from a single individual's efforts but from collective teamwork.
• Trust, openness, knowledge, skills, diverse professional abilities, and commitment are necessary parts of all interactions toward safe, equitable, and effective patient-centered care.

Professional Practice Evaluation

• The Scope and Standards of Practice (ANA, 2021) specify practice competencies in professional practice evaluation as: "engag[ing] in self-reflection and self-evaluation of nursing practice on a regular basis, identifying areas of strength as well as areas in which professional growth would be beneficial" (p. 103).
• Self-regulation involves both the individual professional and the profession that sets standards (ANA's Nursing's Policy Statement: The Essence of the Profession, 2010) and covers personal accountability for knowledge and participation in peer review (pp. 30-32).
• Professional responsibility and accountability include upholding quality standards and developing and critically analyzing those standards and outcomes. Regulation of nursing practice includes self-regulation beyond a limited job description and professional regulation through the defined scope of practice, continuing education, certification, and adherence to the code of ethics.
• Professionals are responsible and answerable to patients and their significant others for nursing care outcomes. Feedback from patients and professional colleagues should be included in practice evaluation.
• Nurses supervise, delegate, and evaluate others. Reflection on professional performance aids practice improvement and is a key component of the peer review process and annual performance evaluation.
• The peer review process is a learning opportunity for both the reviewer and the person being evaluated; it is more than a checklist or narrative comment.

Resource Stewardship

• Resource stewardship recalls efficiency in quality care. Innovative and changed practices for improved patient outcomes must address human needs, environment, concept of health, and care techniques/technologies.
• The ANA (2021) Scope and Standards of Practice describes resource stewardship as not only the appropriate use of resources but also ensuring that nursing care is “safe, effective, financially responsible, and used judiciously” ($p. 105$).
• The focus remains on outcomes and the nurse’s vital role in promoting safe, equitable outcomes. In the healthcare environment, safety and obtaining appropriate resources, supplies, and care provision are essential.
• Understanding cost factors and patient concerns and resources is necessary, including social determinants of health (SDOH): $ext{economic stability}, ext{education access and quality}, ext{healthcare access and quality}, ext{neighborhood and built environment}, ext{social and community context}$.
• Example: an individual with asthma must have access to short-term rescue and long-term controller medications, proper use, environmental adjustments, and support to manage chronic conditions at home; the nurse considers safety at home and the value of treatments and resources to obtain needed meds/treatment.
• The professional nurse considers safe, equitable, and effective care beyond the treatment facility, with attention to human beings, the environment, and health as part of care for positive outcomes.

Environmental Health

• Nursing emphasizes the environment as central to health and care; safety and health risks require constant attention.
• Health professionals and consumers were alarmed by IOM/NASEM reports on high medical errors; these catalyzed ongoing patient safety improvements in hospital and community settings.
• The Institute of Medicine (IOM; now National Academies of Sciences, Engineering, and Medicine) provides science-based advice. The 2001 report Crossing the Quality Chasm proposed 10 rules for quality healthcare; the six overarching aims are: safe, effective, patient-centered, timely, efficient, and equitable (Corrigan et al., 2001).
• Health equity has gained additional attention due to health disparities highlighted during the COVID-19 pandemic. The Future of Nursing 2020-2030 (NASEM, 2021) urges nursing leadership toward health equity, with initiatives in: improving access to care, interprofessional collaboration, nursing leadership, nursing education, nursing workforce data, diversity in nursing, and building healthier communities (RWJF).
• BOX 1.3: Rules for the 21st Century Health System include:
  • Care is based on continuous healing relationships.
  • Care is customized according to patient needs and values.
  • The patient is the source of control.
  • Knowledge is shared, and information flows freely.
  • Decision making is evidence based.
  • Safety is a system property.
  • Transparency is necessary.
  • Needs are anticipated.
  • Waste is continuously decreased.
  • Cooperation among clinicians is a priority.
    (Corrigan, M. S., et al. 2001, pp. 61-62; $pp. 61-62$)
• Research by the Agency for Healthcare Research and Quality (AHRQ) continues to expand knowledge about how the quality of the healthcare workplace affects care quality, including workload, working conditions, stress/fatigue, adverse events, organizational climate, and culture.
• Nurses play an essential role in active attention to the environment and factors that could place patients or providers at risk (e.g., product defects, risky medication practices, environmental artifacts like noise, other hazards, abusive behaviors, SDOH).
• Environmental health is integral to ensuring care that is safe, effective, patient-centered, timely, efficient, and equitable.
• The final emphasis: fulfilling standards of professional performance requires ongoing professionalism. Return to school is framed as a chance to celebrate talents, drawn from adult learners’ rich experiences, with careful examination of personal context and meaning.

BOX 1.3 Rules for the 21st Century Health System

• Care is based on continuous healing relationships.
• Care is customized according to patient needs and values.
• The patient is the source of control.
• Knowledge is shared, and information flows freely.
• Decision making is evidence based.
• Safety is a system property.
• Transparency is necessary.
• Needs are anticipated.
• Waste is continuously decreased.
• Cooperation among clinicians is a priority.

Health Equity Context and IOM/NASEM Initiatives

• The IOM (now NAS) 2001 Crossing the Quality Chasm framework proposes six aims and ten rules to guide a 21st-century health system.
• The 2011 NAS/IOM and subsequent reports emphasize nursing leadership toward improving health equity, with initiatives from organizations like AARP and RWJF to expand access, collaboration, leadership, education, data, diversity, and healthier communities.
• The 2020-2030 Future of Nursing report reinforces nurses’ leadership role in advancing health equity through broad system-level actions.

Returning to School (Adult Learner Perspective)

• Returning to school is a time to celebrate the talents adult learners bring—the wealth of experiences, not the structural constraints typical of traditional schooling.
• Adult learning requires careful examination of personal context to understand the meaning of educational experiences.
• Reasons for returning to school may include recognition for prior work and potential pay differential on the career ladder; these considerations exist alongside opportunities for professional growth and improved patient care.
• Considerations include how experiences shape learning, the relevance of outcomes to practice, and how ongoing education supports professional development and patient outcomes.