Policy/Theory Exemplar
Contributor: Maria Müller Staub, PhD, EdN, RN, FEANS, FNI
June 16, 2019

Year of implementation

The process of the new legislation is ongoing; a vote will take place in the year 2020.

Scope

This report was written to substantiate health care law, as in our country (Switzerland) we took initiative that the scope of nursing practice, its own body of knowledge has to be outlined in the health care law, and that nurses are to be accepted as a specific health care profession to be payed for nursing as an own profession.

Policy summary

This expert report describes the independent responsibilities of nursing against the background of the parliamentary initiative “Legal Recognition of Nursing Responsibilities.” According to its focus on the promotion of nursing science, the Swiss Association of Nursing Science (ANS) has based this report on the current state of the literature. The outcomes of the report are:

• The core business of professional nursing is to assume responsibility for the nursing process. Currently tertiary level (baccalaureate) educated registered nurses are trained and are responsible for the specification, implementation, and evaluation of nursing tasks.
• The aim of the initiative for the legal recognition of nursing responsibilities is to assure that the responsibilities that nurses are already assuming are recognized by the Health Insurance Act. It does not relate to an extension of nursing tasks. Studies reveal that nurses being deployed in accordance with their competencies help to reduce costs.
• Taking responsibility for the implementation of the nursing process is characterized by nurses’ professional relationship with patients and critical thinking.
• The nursing process is based on clinical decision-making and comprises five steps: assessment, nursing diagnoses, outcome planning, implementation of nursing interventions and evaluation.
• These steps are scientifically substantiated by the NNN ( see NANDA-I,  the Nursing Interventions Classification [NIC] and the Nursing Outcomes Classification [NOC] sources). The NNN comprises clearly defined, validated and internationally recognized nursing diagnoses, nursing interventions and nursing-sensitive patient outcomes, which enable its indicators to provide proof of efficacy required by the Health Insurance Act.
• The NNN nursing classification represents the body of knowledge of nursing in a common language and defines the responsibilities as well as the performance of registered nursing staff.

Thus, the profession of nursing is a well-defined, independent field. It can present its performance in defined and scientifically recognized classifications and demonstrate their effectiveness. By legally establishing the autonomy of nursing, legal conditions will be created for nursing profession- all to make a contribution to the future development and provision of health care.

Recommendations for Legislation:

• Nurses are legally responsible for the specification and performance of nursing interventions. They have specific competencies for nursing care of sick people and must be able to make full use of these competencies.
• The nursing process with all its steps should be determined by law to be the core task of nursing. This complies with the Swiss training requirements for tertiary level educated nursing professionals and with international regulations (e.g. USA, Austria).
• The NNN nursing classification is used for formulating rules for implementation. This ensures that nursing practice meets the requirements of the Health Insurance Act with regard to efficacy, efficiency and expediency of nursing performance as well as quality management.

The legislator creates the legal framework so that nurses can take responsibility for their own field of activity, independent of medical doctors. In health care, cooperation among professional groups on equal footing is increasingly gaining importance.

Nursing perspective

This expert report focuses on the body of knowledge in nursing and to name this unique body by using Standardized Nursing Languages to apply the Advanced Nursing Process.

Body of nursing knowledge means specifically the independent nursing content as the specific knowledge, which nurses use to solve (patient/family) problems. The “body of knowledge” is established in science as well as in practice, and it allows an in-depth understanding of the specific problems that a profession addresses, and the issues of the respective target group. In the case of *nursing,* the target group is patients and their significant others/families.

Professions often define the ‘body of knowledge’ in their field in three areas, the so-called “triptych”. The term “triptych” derives from the Greek *triptychos* and means triplicate, consisting of three layers or piles. In the context of nursing, this tripartite structure consists of “diagnosis-intervention-outcomes”, and is characteristic for the profession: *Nursing diagnoses *describe human response/experience to health conditions/life processes (NANDA-I), *nursing interventions* define specialized knowledge and actions to solve patients’ problems (NIC), and lastly,* nursing-sensitive outcomes* are achieved by nurses’ interventions and commonly with patient’s (NOC).

The Advanced Nursing Process can be linked to: ‘Overview of the Structure of Contemporary Disciplinary Knowledge‘ (Jacqueline Fawcett), under ‘situation specific theories‘ (page 5), and specifically with page 12 ‚ Metaparadigm of Nursology – Nursing Processes. The “regular“ nursing process means the model in phases (lacking specific content / knowledge); whereas the *Advanced Nursing Process* contains Standardized Nursing Language = concepts of nursing diagnoses, interventions and outcomes as described in the NNN classification.

This means, philosophies and conceptual nursing models are much more abstract, whereas the *Advanced Nursing Process is concrete (each nursing diagnosis has a title with definition, defining characteristic and related factors; each nursing intervention has title with a definition and activities; and each nursing outcome has a title, definition and indicators (making the outcome measurable).*

Key nurses and their roles

Maria Müller Staub, PhD, EdN, RN, FEANS, FNI
Professor in Nursing Diagnostics, Hanze University Groningen (NL), former Professor in Acute Care, ZHAW University, Winterthur (Switzerland). Researcher specialized in: Nursing Theories/Models, Advanced Nursing Process, Nursing Diagnostics and Critical Thinking, Electronic Health Record Development, Nursing Assessment & Diagnoses Development and Validation.
Supports and fosters the the recognition of nursing as a profession with its own, specific body of knowledge, was President of the Swiss Nursing Sciene Association (2011-2017) representing nine academic nursing societies, is currently President of ACENDIO.

Judith Abt, MNS, RN
Clinical Nurse Specialist, Quality Management and Nursing Development, Oncology Nursing, Aarau (Switzerland). Specialized in Nursing Theories and the Nursing Process by using a Standardized Nursing Language to represent the body of knowledge.

Andrea Brenner, Dr. phil., RN
Professor in Nursing, University of Applied Sciences St. Gallen (Switzerland). Lecturer Advanced Nursing Process, Nursing Diagnostics, Evidence-based Nursing, Nursing Research and Management of Chronic Wounds.

Brigitte Hofer, MA phil., RN
Masters Degree in Philosophy / Ethics prepared Clinical Care Specialist and former nurse educator; with a vast experience in health care policy development at the national level aiming to foster the recognition of nursing as a profession with its own, specific body of knowledge.

Outcomes

See the report here. We will add more information on the outcomes when the legislative process is concluded.

Contributor Biosketch

Maria Müller-Staub is Professor at the Lectoraat for Nursing Diagnostics at the Hanze University Groningen, Netherlands, and Head of Nursing Development and Research at the Cityhospital Waid in Zürich, Switzerland. She worked on more than 40 research projects, mainly as principal investigator, and is founder of Pflege PBS (Nurse Consulting, Teaching, & Research), Wil. Prof. Müller-Staub’s main focus is on nursing diagnostics, clinical decision-making and critical thinking, e-Health, nursing documentation, nursing care quality and Clinical Information Systems (CIS). She consults healthcare institutions and nursing education program developers for implementing nursing language related to the classifications of nursing diagnoses, interventions and outcomes (NANDA-I, NIC & NOC).

Prof. Müller-Staub teaches in post-graduate nursing programs and supervises doctoral students. She is an expert in curriculum development and was Dean of a nursing school offering advanced degree pro-grams.

Prof. Müller-Staub is President of the Swiss Association for Nursing Research, representing nine Aca-demic Societies: Cardiovascular Nursing, Patient Education, Nursing Ethics, Gerontology Nursing; Home Health Nursing, Oncology Nursing, Pediatric Nursing, Psychiatric Nursing and Rehabilitation Nursing.
Prof. Müller-Staub has published over 272 scientific articles (123 in peer-reviewed/indexed, 103 non-peer-reviewed, 46 books/book chapters), held over 179 conference presentations, and is a lecturer in national and international nursing programs.