Standards of Care for Nurse Practitioner Practice
The traditional definition of standard of care has been, “such reasonable, ordinary care, skill, and diligence as used by practitioners in good standing in the same general type of practice, in similar cases.” Today, NPs and other clinicians are judged not only by what other clinicians would do, but by what is best for the patient. Today, the standard of care addresses the questions:
Did the clinician do the right thing at the right time?
Was effective care provided to the patient?
Was care provided safely and in an appropriate time frame?
Was the outcome as good as expected, given the patient’s condition and personal characteristics and the current state of medical science?
▪ Who Is Monitoring Standard of Care?
In the past, compliance with standard of care was voluntary, performance was not measured, performance was not reported to the public, and often, the standard of care for a particular set of circumstances became clear only after a mistake was made, a lawsuit was filed, expert witnesses were hired, dual versions of the “standard of care” were argued by both sides of a malpractice case, and a jury accepted one or the other side’s version. Today, while the standard of care for NPs still may be scrutinized in a court of law, there is a recognition that a minimum acceptable level of care may be determined outside the judicial system by consensus, with participation by consumers, providers, and agencies. The standards that are being developed will be continually reassessed and reset on the basis of results of outcomes research, analysis of costs and benefits, and results of patient satisfaction measures.
The 1990s brought increased attention to quality standards for health care from people outside the medical profession, namely consumers and government agencies. That initiative has continued in the 21st century. Corporate and government purchasers of
health services have joined medical and nursing professional organizations, licensing boards, and the judicial system in setting standards for healthcare providers. Standards of care are being monitored, publicized, and changed by the government and by several national consumer-oriented groups. Traditionally, standards of medical and nursing care were developed by clinicians and monitored by:
health services have joined medical and nursing professional organizations, licensing boards, and the judicial system in setting standards for healthcare providers. Standards of care are being monitored, publicized, and changed by the government and by several national consumer-oriented groups. Traditionally, standards of medical and nursing care were developed by clinicians and monitored by:
Professional societies
Licensing boards
The Joint Commission on Hospitals
The judicial system
Employers
Standards of care are now being set, modified, monitored, and publicized by certain self-appointed consumer-oriented agencies as well as government agencies. Those groups include:
National Committee for Quality Assurance (NCQA)
Joint Commission on Accreditation of Healthcare Organizations (Joint Commission)
Agency for Healthcare Research and Policy (AHRP)
Medicare
Professional Societies
The American Academy of Nurse Practitioners (AANP) has written the following standards for the process of care:*
Assessment of Health Status
The nurse practitioner assesses health status by:
Obtaining a relevant health and medical history.
Performing a physical examination based on age and history.
Performing or ordering preventive and diagnostic procedures based on the patient’s age and history.
Identifying health and medical risk factors.
Diagnosis
The nurse practitioner makes a diagnosis by:
Utilizing critical thinking in the diagnostic process.
Synthesizing and analyzing the collected data.
Formulating a differential diagnosis based on history, physical examination, and diagnostic test results.
Establishing priorities to meet the health and medical needs of the individual, family, or community.
Development of a Treatment Plan
The nurse practitioner, together with the patient and family, establishes a mutually acceptable cost awareness plan of care that maximizes health potential. Formulation of the treatment plan includes:
Ordering additional diagnostic tests.
Prescribing/ordering appropriate pharmacologic and nonpharmacologic interventions.
Developing a patient education plan.
Appropriate consultation/referral.
Implementation of the Plan
Interventions are based upon established priorities. Actions by the nurse practitioner are:
Individualized.
Consistent with the appropriate plan of care.
Based on scientific principles, theoretical knowledge, and clinical expertise.
Consistent with teaching and learning opportunities.
Actions include:
Accurately conducting and interpreting diagnostic tests.
Prescribing pharmacologic agents and nonpharmacologic therapies.
Providing relevant patient education.
Making appropriate referrals to other health professionals and community agencies.
Follow Up and Evaluation of the Clients’ Status
The nurse practitioner maintains a process for systematic follow up by:
Determining the effectiveness of the treatment plan with documentation of patient care outcomes.
Reassessing and modifying the plan as necessary to achieve medical and health goals.
Care Priorities
The nurse practitioner’s practice model emphasizes:
Patient and Family Education The nurse practitioner provides health education and utilizes community resource opportunities for the individual and/or family.
Facilitation of Patient Participation in Self Care The nurse practitioner facilitates patient participation in medical and health care by providing information needed to make decisions and choices about the:
Promotion, maintenance, and restoration of health
Consultation with other appropriate healthcare personnel
Appropriate utilization of healthcare resources
Promotion of optimal health
Provider of continually competent care
Facilitation of entry into the healthcare system
The promotion of a safe environment
Interdisciplinary/Collaborative Responsibilities
As a licensed, independent practitioner, the nurse practitioner participates as a team leader and member in the provision of health and medical care, and interacting with professional colleagues to provide comprehensive care.
Accurate Documentation of Patient Status and Care
The nurse practitioner maintains accurate, legible, and confidential records.
Responsibility as Patient Advocate
Ethical and legal standards provide the basis of patient advocacy. As an advocate, the nurse practitioner participates in health policy activities at the local, state, national, and international levels.
Quality Assurance and Continued Competence
Nurse practitioners recognize the importance of continued learning through:
Participation in quality assurance review, including systematic review of records and treatment plans on a periodic basis
Maintenance of current knowledge by attending educational programs
Maintenance of certification in compliance with current state law
Applying standardized care guidelines in clinical practice
Adjunct Roles of Nurse Practitioner
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