SOHN Nurse

Scope and Standards of Otorhi. and Head-Neck Nursing Practice

scopeAndStandards

Scope and Standards of Otorhinolaryngology and Head-Neck Nursing Practice

Second Edition

 

Publisher: Society of Otorhinolaryngology and Head-Neck Nurses, Inc.
207 Downing Street
New Smyrna Beach, Florida 32168

Copyright © 2009 by Society of Otorhinolaryngology and Head-Neck Nurses

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system without permission in writing from the publisher. Permissions may be sought directly from the Society of Otorhinolaryngology and Head-Neck Nurses, Inc in New Smyrna Beach, Florida, USA: phone: (386) 428-1695, fax: (386) 423-7566, email: [email protected].

ISBN#: 978-0-9799451-1-3
Printed in the United States of America
First Edition 1994, Second Edition 2009
© 2009 SOHN. All rights reserved.

ACKNOWLEDGEMENTS

The Society of Otorhinolaryngology and Head-Neck Nurses gratefully acknowledges the valuable assistance, comments, and recommendations given by expert nurses across the country who have collaborated through the initial publication and on-going revisions of this document.

Original Authors

Standards of Practice Committee (1992-93)

Linda Schuring, MSN, RN, Chairperson

Barbara Sigler, MNEd, RN, CORLN, Vice Chairperson

Workgroups

National Practice Committee (2003, 2006)

Ann Luther, MSN, RN, CORLN, Chairperson 2003

Cindy Dawson, MSN, RN, CORLN, Chairperson 2006

Field Reviewers (2007-2008)

Linda Schuring, MSN, RN

Barbara Sigler, MNEd, RN

Connie Yuska Bildstein, MSN, RN, CORLN

Linda Miller Calandra, MSN, RN, CRNP, CORLN

Linda Clarke MS, RN, CORLN

Cindy Dawson, MSN, RN, CORLN

Mary Huntoon, MSN, RN, CORLN

Sarah Kagan, PhD, RN, FAAN

Helene Krouse, PhD, APRN, BC, CORLN, FAAN

Sandra Schwartz, MS, RN, CORLN

 

Table of Contents

Acknowledgements
Preface
Introduction
Scope of Practice for ORL Nursing
Standards of Clinical ORL Nursing Care

I. Assessment
II. Diagnosis
III. Outcome Identification
IV. Planning
V. Implementation
VI. Evaluation

Standards of Professional Performance

I. Quality of Care
II. Practice Evaluation
III. Education
IV. Collegiality
V. Ethics
VI. Collaboration
VII. Research
VIII. Resource Utilization
IX.Futurism/Leadership

Glossary
References

 

Preface

The development of nursing standards has been a goal of the American Nurses Association (ANA) since the late 1960’s (Oncology Nursing Society [ONS], 2004). The Society of Otorhinolaryngology and Head-Neck Nurses (SOHN) began developing standards in the late 1970’s (ANA, 1994). SOHN published the Standards of Otorhinolaryngology and Head-Neck Nursing Practice in 1986 and the Scope of Otorhinolaryngology Nursing Practice in 1988 (ANA, 1994).

The American Nurses Association published the first Standards of Clinical Nursing Practice in 1991 (ANA, 1991). The project was a collaborative effort among the ANA Committee on Nursing Practice, Standards, and Guidelines and other specialty nursing organizations, including SOHN. Using the common language and regular format provided in Standards of Clinical Nursing Practice (1991), the Standards and Statement on the Scope of Otorhinolaryngology Clinical Nursing Practice were developed by the SOHN Standards of Practice Committee and the ANA and published in 1994.

The previous version of the Standards and Statement on the Scope of Otorhinolaryngology Clinical Nursing Practice served SOHN nurses. The current revision is timely, addressing the myriad of changes and challenges Otorhinolaryngology (ORL) nurses encounter in health care today. SOHN publishes this scope and standards and serves as sole source.

Introduction

Standards are authoritative statements by a profession that describe the requisite knowledge and scope of practice for which practitioners are accountable. Standards reflect the values and priorities of the profession, providing direction for nursing practice, research, and a framework for practice evaluation.

The scope and standards require continuous refinement to reflect the evolving dynamics of the ORL patient and the changing needs and demands of healthcare (ANA, 2001). The growing body of nursing research and evidence-based practice provides the method to ensure competent, safe, effective clinical practice and promote professional ORL nurse development.

SOHN believes that quality care is the primary nursing responsibility. In measurable terms, the Scope and Standards of Otorhinolaryngology and Head-Neck Nursing Practice defines ORL nurses’ accountability and responsibility. SOHN must define the practice of ORL nursing within the framework of clinical standards. These standards identify measurable patient outcomes. The quality, appropriateness, and effectiveness of this nursing care must be evaluated.

The term ‘family unit’ used throughout the document defines family members, significant other(s) and/or community involved in the patient’s care.

The Scope and Standards of Otorhinolaryngology and Head-Neck Nursing Practice delineates the professional responsibility of all registered nurses engaged in ORL practice, regardless of setting. The standards could serve as a basis for:

• Quality assurance systems
• Research
• Regulatory systems
• Healthcare reimbursement and financing methodologies
• Development and evaluation of nursing delivery systems and organizational structures
• Certification
• Position descriptions and performance appraisals
• Agency policies, procedures, and protocols
• Education
• Publications

The document is developed to set forth both the scope and standards of ORL nursing practice. The standards describe a level of competence for professional nursing care and performance for nurses practicing in the ORL specialty.

Scope of Practice for ORL Nurses

Purpose

The purpose of this ‘Scope of Practice’ is to:

• Define ORL nursing practice;
• Provide a framework for professional growth and development; and,
• Outline the responsibility and accountability of ORL nurses.

Definition

ORL and Head-Neck nursing practice is defined as the care of the patient and family unit who have past, current or potential ORL conditions. Subspecialties include, but are not limited to: otology, neurotology, rhinology, allergy, laryngology, pediatric, adult, and geriatric ORL, perioperative ORL, facial plastic and reconstructive surgery, head and neck oncology, and skull base surgery. Cross-specialty knowledge in other fields is critical to ORL practice and care. The medical and surgical cross specialties include genetics, ophthalmology, oral surgery, neurology, general surgery, dermatology, radiology, pathology, and gastroenterology. The nursing practice of ORL and Head-Neck demands cross-cultural and intergenerational competence. These are interdependent to ORL practice.

Types of Practitioners

ORL Nurse

The registered nurse is practicing in the ORL specialty.

ORL Certified Nurse

The certified registered nurse is practicing with certification (Certified Otorhinolaryngology Nurse [CORLN]) in the ORL specialty.

ORL Advanced Practice Nurse

The advanced practice registered nurse is practicing with a graduate degree in nursing with a specialization in a clinical area (MacDonald, Herbert and Thibeault, 2006).

Functions and Responsibilities

ORL Nurse

  • Collects data regarding the health status of the patient, in a systematic and ongoing manner
  • Applies appropriate theory as the basis for decision-making in evidence-based nursing practice
  • Maintains competency in observation, conceptualization, nursing diagnosis, and analysis of ORL clinical care
  • Communicates relevant data, maintaining patient confidentiality, within an ethical framework
  • Develops nursing diagnoses from health status data
  • Formulates measurable goals with the patient and family unit, according to the patient’s immediate condition or needs
  • Develops a plan for patient care which satisfies goals and facilitates the expected patient outcomes
  • Implements the nursing plan to promote, maintain, or restore health; prevent illness; and, effect rehabilitation
  • Evaluates the patient’s response to the plan of care
  • Reassesses and prioritizes goals, sets new goals, and revises the plan of care
  • Collaborates with other professionals and specialists to facilitate a interprofessional approach to patient care
  • Assists individuals, family units, and community groups to achieve optimal levels of wellness through health education
  • Participates in peer review and other methods of evaluation to effect quality patient care
  • Reflects in practice, knowledge of current professional standards, state and federal laws and regulations
  • Assumes responsibility for professional self-development, clinical competence, and continuing education, including participation in SOHN and other relevant organizations
  • Integrates research in practice

ORL Certified Nurse

  • Incorporates the functions and responsibilities of the ORL nurse
  • Collaborates with the healthcare system to develop and maintain comprehensive ORL educational and treatment programs
  • Contributes to the education and professional growth of nurses and other members of the healthcare team
  • Participates in the identification of ORL nursing research questions
  • Monitors legislative and regulatory issues related to ORL nursing
  • Maintains CORLN certification
  • Disseminates knowledge of clinical practice and research findings through publications and presentations
  • Uses ORL specialty knowledge and clinical expertise in providing health care

ORL Advanced Practice Nurse

  • Incorporates the functions and responsibilities of the ORL nurse and ORL certified nurse in the advanced practice role
  • Monitors legislative and regulatory issues related to both ORL and advanced practice nursing
  • Provides both medical and nursing care to prevent, diagnose, and treat common acute and stable chronic ORL conditions
  • Functions, with prescriptive authority per state and institutional regulations, as an adjunct to medical and nursing management of actual or potential health problems
  • Refers patients to clinical services and consults with these services regarding the appropriate follow-up or management
  • Participates in interprofessional teams which evaluate clinical practice and patient care or health services
  • Evaluates patient care delivery models
  • Participates in ongoing educational activities related to clinical knowledge and professional issues
  • Collaborates with colleagues to enhance professional nursing practice
  • Serves as an ORL consultant within the healthcare system
  • Seeks available resources in formulating ethical decisions
  • Identifies ORL nursing research questions
  • Participates in research activities as appropriate to the advanced practice nurses’ education and position
  • Utilizes advanced knowledge and clinical expertise to address the complex health needs of the patient and family unit

Summary

The ORL nursing “Scope of Practice” strengthens SOHN’s commitment to the ideals and purposes of this humanitarian profession. The statement promotes the profession by identifying the purpose, definition, types of practitioner, and functions and responsibilities of nurses in the ORL specialty.


Standards of ORL Nursing Care

Standard I. Assessment

The ORL nurse collects patient health data.

Rationale

Information obtained from patients, family units, and the interprofessional team and nursing knowledge is used to develop a plan of care. The assessments are specific to age, developmental level, gender, and are culturally and ethnically appropriate.

Measurement Criteria

  1. Prioritizes data collection according to the patient’s immediate condition or needs.
  2. Collects pertinent data using appropriate assessment techniques.
    1. Data are obtained by interview, examination, observation, and review of health records.
    2. Data include, but are not limited to:
      1. Perceptions and expectations related to health care
      2. Knowledge of health maintenance and practice of health promotion and disease prevention activities
      3. Previous access to and utilization of the healthcare system
      4. Current diagnosis/diagnoses, chief complaint, current symptoms, and treatment(s)
      5. Environmental, occupational, recreational, psychosocial, functional, cultural, and spiritual information
      6. Past medical history
      7. Review of systems
  3. Involves the patient, family unit, and/or healthcare providers in data collection.
  4. Collects data in a systematic and ongoing way.
  5. Documents relevant data.

Standard II. Diagnosis

The ORL nurse analyzes the assessment data to determine nursing diagnoses.

Rationale

The ORL nurse, independently or in collaboration with interprofessional care providers, evaluates health assessment data to develop diagnoses, which guide interventions.

Measurement Criteria.

  1. Determines nursing diagnoses are derived from the assessment data and medical record.
  2. Validates nursing diagnoses with the patient, family unit, and/or health care providers.
  3. Documents nursing diagnoses to determine a plan of care and identify expected outcomes.

Standard III. Outcome Identification

The ORL nurse identifies expected outcomes individualized to the patient.

Rationale

The goals in providing ORL nursing care are to influence health outcomes and improve or maintain the health status of the ORL patient of all ages. Outcomes focus on maximizing the state of well-being, health promotion and maintenance, functional status, and quality of life.

Measurement Criteria

  1. Derives expected outcomes from the nursing diagnosis.
  2. Documents expected outcomes as measurable goals according to evidence-based practice and established guidelines.
  3. Assigns a realistic time estimate for expected outcomes attainment.
  4. Develops expected outcomes collaboratively with the patient, family unit, and healthcare providers.
  5. Ensures outcomes are realistic in relation to the patient’s present and potential capabilities and resources.
  6. Ensures expected outcomes provide direction for continuity of care.

Standard IV. Planning

The ORL nurse develops a plan of care, which prescribes interventions to attain expected outcomes.

Rationale

A plan of care is used to structure and guide nursing intervention and to facilitate the achievement of expected outcomes and continuity of care.

Measurement criteria

  1. Ensures the ORL plan of care is individualized to the patient’s conditions or needs by considering:
    1. The skills necessary for self-care
    2. The patient’s readiness to learn and the use of appropriate teaching methods
    3. Options to meet needs
    4. An interprofessional approach to care
  2. Develops the plan of care in collaboration with the patient, family unit, and healthcare providers.
  3. Ensures the plan reflects current ORL nursing practice and includes:
    1. Priorities for nursing action
    2. A logical sequence of actions to attain the outcomes
    3. A current scientific knowledge base
    4. Appropriate and available resources
    5. Consideration of the patient’s rights and responsibilities
  4. Communicates the plan of care to all members of the interprofessional team.
  5. Documents and updates the plan to provide continuity of care.

Standard V. Implementation

The ORL nurse implements the interventions identified in the plan of care.

Rationale

The ORL nurse uses a range of culturally competent interventions. The interventions include health promotion and maintenance, prevention and early detection, health restoration, rehabilitation, and palliation. The goal is to affect the patient’s overall health, well-being, comfort, and quality of life in collaboration with the patient and family unit.

Measurement Criteria

  1. Implements interventions in a timely manner according to established plan of care and guidelines.
  2. Ensures that interventions are implemented in a safe, appropriate, caring, and holistic manner considering cultural and generational components.
  3. Documents interventions and patient responses.

Standard VI. Evaluation

The ORL nurse evaluates the patient’s progress toward attainment of outcomes.

Rationale

ORL nursing practice is dynamic and requires ongoing evaluation. Evaluation includes the continuous review of nursing diagnoses and response to treatment and interventions. Collecting new information, revising assessments, and altering diagnoses and plans of care are essential components of evaluation.

Measurement Criteria

  1. Maintains an evaluation process that is systematic and ongoing.
  2. Documents and communicates patient’s responses to interventions.
  3. Evaluates the effectiveness of interventions based on patient outcomes.
  4. Uses ongoing assessment data to revise diagnoses, outcomes, and the plan of care.
  5. Documents revisions in diagnoses, outcomes, and the plan of care.
  6. Ensures the patient, family unit, and healthcare providers are involved in the evaluation process.

 

Standards of Professional Performance

Standard I. Quality of Care

The ORL nurse systematically evaluates the quality and effectiveness of nursing practice.

Rationale

The increasing body of ORL nursing knowledge and evidence-based practice provides opportunities to improve quality of care and effectiveness of nursing practice.

Measurement Criteria

The ORL Nurse

  1. Participates in quality of care activities as appropriate to position, education, and practice environment. Such activities may include:
    1. Identifying aspects of care important for quality monitoring
    2. Identifying indicators used to monitor quality and effectiveness of ORL nursing care
    3. Collecting data to monitor quality, safety and effectiveness of ORL nursing care using national benchmarks
    4. Analyzing data to identify opportunities for improving care
    5. Formulating recommendations to improve ORL nursing practice or patient outcomes in collaboration with medical specialty for ORL-Head and Neck Surgery
    6. Implementing activities to enhance the quality of ORL nursing practice
    7. Participating on interprofessional teams that evaluate clinical practice or health services
    8. Developing policies and procedures to improve quality of care
  2. Uses the results of quality of care activities to initiate changes in practice and throughout the healthcare delivery system, as appropriate.

Standard II. Practice Evaluation

The ORL nurse evaluates own nursing practice in relation to professional practice standards and relevant statutes and regulations.

Rationale

The ORL nurse is accountable for competent care with responsibility to practice according to stated standards.

Measurement Criteria

The ORL Nurse

  1. Engages in performance appraisal on a regular basis, identifies strengths, and areas for professional and practice development.
  2. Seeks constructive feedback regarding practice.
  3. Takes action to achieve goals identified during performance appraisal.
  4. Participates in peer review.
  5. Serves as a role model/mentor for new nurses.
  6. Seeks and encourages CORLN certification to validate professional practice.

Standard III. Education

The ORL nurse acquires and maintains current knowledge in nursing practice.

Rationale

Continuing education, certifications, and formal education are learning opportunities and avenues to maintain and pursue on-going professional growth. The need for education is dependant on societal, cultural, and political changes in the diverse environment.

Measurement Criteria

The ORL Nurse

  1. Participates in on-going educational activities related to clinical knowledge and professional issues.
  2. Seeks experiences to maintain clinical skills.
  3. Seeks knowledge and skills appropriate to the practice setting.
  4. Joins and remains active in professional organizations, such as the SOHN, ANA, the National Gerontological Nursing Association, ONS, and other relevant organizations.
  5. Seeks to achieve and maintain specialty certification – CORLN.

Standard IV. Collegiality

The ORL nurse contributes to the professional development of peers, colleagues, and others.

Rationale

The ORL nurse is responsible for sharing knowledge with healthcare colleagues using various teaching methodologies.

Measurement Criteria

The ORL Nurse

  1. Shares knowledge and skills with interprofessional groups.
  2. Provides peers with constructive feedback regarding their practice.
  3. Contributes to an environment conducive to the education of healthcare students, as appropriate.
  4. Mentors and precepts nurses in the specialty.

Standard V. Ethics

The ORL nurse makes decisions and acts on behalf of patients, which are determined in an ethical manner.

Rationale

The current environment in healthcare demands the ORL nurse to consider patient rights and elicit the public’s trust in the provision of care.

Measurement Criteria

The ORL Nurse

  1. Guides practice by the ANA Code of Ethics for Nurses with Interpretive Statements (2001).
  2. Maintains patient confidentiality by adhering to Health Insurance Portability and Accountability Act of 1996 (HIPAA, 2006).
  3. Maintains a safe environment adhering to the Joint Commission National Patient Safety Goals (The Joint Commission, 2007).
  4. Acts as a patient advocate.
  5. Delivers care in a nonjudgmental and nondiscriminatory manner, sensitive to patient diversity.
  6. Delivers care in a manner which preserves and protects patient autonomy, dignity, and rights with particular consideration and sensitivity to alterations in communication, other functional disorders, and potential physical disfigurements specific to ORL diagnosis.
  7. Seeks available resources to assist in ethical decision-making.

Standard VI. Collaboration

The ORL nurse collaborates with the patient, family and other healthcare providers in providing care.

Rationale

Collaboration and effective communication between patients and providers is crucial for planning, implementing, and evaluating ORL care.

Measurement Criteria

The ORL Nurse

  1. Communicates with the patient, family unit, and healthcare providers regarding patient care and nursing’s role in the provision of care.
  2. Consults with, and is consulted by, other healthcare providers for patient care.
  3. Makes referrals, including provisions for continuity of care.
  4. Participates in community outreach activities.

Standard VII. Research

The ORL nurse applies research findings to practice.

Rationale

ORL nurses need active involvement in all stages of research and evidence-based practice. The future of ORL nursing depends on validated practice and improved outcomes.

Measurement Criteria

The ORL Nurse

  1. Uses substantiated research to provide best evidence for practice foundation that is consistent with position, education, and practice environment.
  2. Participates in research activities consistent with position, education, and practice environment. Such activities may include:
    1. Identifying clinical problems suitable for ORL nursing research
    2. Collecting and analyzing data
    3. Participating in an organization or community research committee or program
    4. Sharing research activities and outcomes
    5. Conducting research following institutional and federal guidelines for protection of human subjects
    6. Analyzing research for application to practice
    7. Integrating research findings in the development of policies, procedures, and guidelines for patient care
  3. Publishes and/or presents on ORL best nursing practices.

Standard VIII. Resource Utilization

The ORL nurse considers factors related to safety, effectiveness, and cost in planning and delivering patient care.

Rationale

The ORL patient population demands healthcare that is safe, effective, and affordable and provided using appropriate and available resources.

Measurement Criteria

The ORL Nurse

  1. Evaluates and integrates factors related to safety, effectiveness, and cost in practice setting.
  2. Assumes leadership in the individualized education of the patient and family unit, securing appropriate resources.
  3. Assigns tasks or delegates care based on the needs of the patient and the knowledge and skill of the provider selected.
  4. Helps the patient and family unit to identify and secure appropriate services to address health-related needs.
  5. Responds to current social and political issues, which influence health care by involvement in organization or community.

Standard IX. Futurism/Leadership

The ORL nurse, in a leadership position, anticipates the dynamic nature of ORL- Head and Neck Nursing and prepares for the evolving future.

Rationale

The evolution of ORL nursing practice through evidence-based practice and technological advancements requires nursing leadership to embrace the futuristic trends for the betterment of the patient and family unit.

Measurement Criteria

The ORL Nurse

  1. Mentors peers and colleagues in the work environment.
  2. Anticipates current trends in practice and various practice settings.
  3. Assists with cost and quality issues related to practice and patient learning.
  4. Documents outcomes of interventions and technology innovations in ORL nursing.
  5. Exemplifies critical thinking in practice, patient education program development, and recruiting and retaining satisfied ORL nurses.


GLOSSARY KEY TERMS

ASSESSMENT. A systematic, dynamic process by which the nurse-through interaction with the patient, family unit, and healthcare providers-collects and analyzes data about the patient. Data may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, functional abilities, and lifestyle.

CONTINUITY OF CARE. An interprofessional process that includes the patient and family unit in the development of a coordinated plan of care. This process facilitates the patient’s transition between settings, based on changing needs and available resources.

CRITERIA. Relevant, measurable indicators of the standards of clinical nursing practice.

DIAGNOSIS. A clinical judgment about the patient’s response to actual or potential health conditions or needs. Diagnoses provide the basis for determination of a plan of care to achieve expected outcomes.

EVALUATION. The process of determining both the patient’s progress toward the attainment of expected outcomes and the effectiveness of nursing care.

EVIDENCE-BASED PRACTICE. The integration of best existing nursing and medical research evidence with clinical expertise and patient values (Burns & Grove, 2005; Sackett, Straus, Richardson, Rosenberg & Haynes, 2000).

FAMILY UNIT. Family members, persons significant to the patient, and/or the community.

GUIDELINES. Systematically developed statements based on available scientific evidence and expert opinion. They describe a process of patient care management that has the potential for improving the quality of clinical and consumer decision making.

HEALTHCARE PROVIDERS. Individuals with special expertise who provide health- care services or assistance to patients (e.g. nurses, physicians, psychologists, social workers, nutritionists/dietitians, speech language pathologists, physical therapists, and a variety of other therapists). Providers also may include service organizations and vendors.

IMPLEMENTATION. May include any or all of these activities: intervening, delegating, and coordinating. The patient, family unit, or healthcare providers are designated to implement interventions within the plan of care.

NURSING. The diagnosis and treatment of human responses to actual or potential health problems.

OTORHINOLARYNGOLOGY (ORL). The branch of medicine dealing with disease of the ear, nose, and throat; also called Otolaryngology-Head and Neck Surgery.

OUTCOMES. Measurable, expected, patient-focused goals.

PATIENT. The recipient of nursing actions. When the patient is an individual, the focus is on the health state, problems, or needs of that person. When the recipient is a family or group, the focus is on the health state of the unit as a whole or the reciprocal effects of an individual’s health state on the other members of the unit. When the recipient is a community, the focus is on personal and environmental health and the health risks of population groups. Nursing actions toward patients may be directed to disease or injury prevention, health promotion, health restoration, and/or health maintenance.

PLAN OF CARE. Comprehensive outline of care to be delivered to attain expected outcomes.

SOCIETY OF OTORHINOLARYNGOLOGY AND HEAD-NECK NURSES (SOHN). A specialty organization for nurses who practice in the field of otorhinolaryngology and head-neck surgery.

STANDARD. Authoritative statement enunciated and promulgated by a profession, by which the quality of practice, service, or education can be judged.

STANDARDS OF CARE. Authoritative statements that describe a competent level of clinical nursing practice demonstrated through assessment, diagnosis, outcome identification, planning, implementation, and evaluation.

STANDARDS OF NURSING PRACTICE. Authoritative statements that describe a level of care or performance common to the profession of nursing by which the quality of nursing practice can be judged. Standards of clinical nursing practice include both standards of care and standards of professional performance.

STANDARDS OF PROFESSIONAL PERFORMANCE. Authoritative statements that describe a competent level of behavior in the professional role, including activities related to quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, resource utilization, and leadership.


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Sackett, D.L., Straus, S.E., Richardson, W.S., Rosenberg, W., & Haynes, R.B. (2000). Evidence-based medicine: How to practice and teach EBM (2nd ed.). St. Louis, MO: Churchill Livingstone.

Society of Otorhinolaryngology and Head & Neck Nurses. (1988). Scope of Practice. New Smyrna Beach, FL: Author.

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The Joint Commission. (2007). Retrieved January 20, 2008 from http://www.jointcommission.org/