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  Last modified September 1, 2004  

A Career in Practice Standards

Taking part in the evolution of nursing.

Trudy Molke, RN, recently retired after 23 years of working at the College of Nurses of Ontario. Trudy was involved in writing many important practice standards and guidelines, including Ethics, Therapeutic Nurse-Client Relationship and Culturally Sensitive Care. Here she gives her observations on how the standards have kept pace with the evolution of nursing.

It is amazing to consider how the practice standards have changed during my career. The changes in nursing, in legislation and in health care have affected the work of the College and of all nurses.

In 1976, the standards were based on the nursing process — assess, plan, implement and evaluate. The standards also included lists of skills — A and B level skills and skills for RNs and RPNs. Many nurses felt that it was these lists, which were frequently outdated, that were the standards and not the nursing process.

Today’s practice standards bare little resemblance to the ones I read 23 years ago. I watched how nursing theorists and new legislation changed care from nurse-focused to client-centered. CNO’s standards often led the way to changes in practice. No longer is nursing a task-oriented profession that needs lists. Today, nursing is a knowledge-based profession with complex decision-making responsibilities.

The College’s standards and guidelines have always been evidence-based because the literature and current research are always consulted during development and revision. Nurse experts are consulted and input is requested from many nurses around the province. As nursing education advances, and nursing knowledge and experience develop, so do the standards.

The practice standards also expanded in response to the questions nurses would ask the College and to the evolution of the practice setting. To keep pace, practice standards expanded to include accompanying practice guideline documents. When I first started at CNO we had two standards. Today, we have nine standards and 19 guidelines.

The move to client-centered care was facilitated by the requirement in the Regulated Health Professions Act to educate members about abuse of clients and to provide guidelines for members’ conduct. The passing of the Health Care Consent Act (1996) enshrined in law the right of clients to be informed and to refuse treatment, moving away from a paternalistic view of health care.

In response, CNO developed a philosophy statement about nurse-client relations and wrote the standard Therapeutic Nurse-Client Relationship. This standard was copied by nursing associations across the country and led to the Restraints standard and the adoption of a least-restraint philosophy. It is also the basis for the guideline Culturally Sensitive Care, a document that explores how nurses can provide safe, effective and ethical care to clients from the many diverse cultures in Ontario.

Quality Practice Settings

A major change in health care and nursing has been the recognition that the organizations where nurses work affect the care that is given. For example, the Canadian Nurses Association has included Quality Practice Environments as one of the values in its Code of Ethics for Registered Nurses.

In the 1990s, the standards began to include a section that advised how quality practice settings could support nurses to meet the standards. In 1996, CNO formally recognized that the workplace could facilitate or impede the provision of quality care and developed the Practice Setting Consultation Program® to help workplaces address issues affecting nursing care

In the Future

The evolution of the profession and of the standards continues.

Nurses have struggled over the past decades with restructuring, cutbacks, layoffs and loss of strong nursing leaders in the workplace. Although many changes have occurred, some things are unchanging. Clients need care, and nurses, who are among the most trusted of health professionals, continue to be concerned about giving quality care.

I have seen the content of the standards change to address new approaches to nursing. An early version of Nursing Documentation gave readers a general overview of the purposes and principles of documentation. By 2002, Documentation was rewritten to describe the specific expectations for nurses, with specific directives, such as the expectation for documenting services provided for groups, communities and populations.

Some may criticize this new approach as too prescriptive and not encouraging of critical thinking or independent decision making, but this may be a sign of where the standards will move next. How will the standards change in relation to new requirements in basic education and the changing health care environment? I will watch new developments with great interest.

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