Evolutionary Psychology and Attraction

Sociobiology, with its focus on biological accounts of evident social facts, has developed into evolutionary psychology, with its stress on the process of the evolution of the brain, and the extent of influence of people’s desire to survive and to multiply their genes into the next generations to their present behavior and conduct (ibid).Sociobiology or evolutionary psychology both in the modern age apply scientific methods of investigation, and subject raw data to quantitative analysis. Any science makes use of speculations, theory, and others. However, these are applied in the service of an empirical framework, and the aged criticisms are nowadays primarily incorrect. The concept of evolution is the adhesive in biology. Carrying this concept into psychology has offered countless new ideas and insights (ibid). Evolutionary psychology is one of the most essential new assumptions of the contemporary times, making use of Darwin’s ideas on evolution and natural selection to the psychological study of humans.There has been, as people think, a paradigm shift in psychology, such that several phenomena clarified in terms of social causation, or impossible to explain at all, are now clarified in the evolutionary psychology discipline. Hence, evolutionary, biological clarifications have turned out to be more often in psychology, while explanations in terms of social psychology, education, or culture have turned out to be observed as less practical (Mortola, 1999). Genes and the environment function together, hence these other regions are not declined, and they merely are not applied as much anymore as the foremost explanation of phenomena. Using the concept of human sexuality, this paper will show how the innovated evolutionary psychology explains significant ideas nowadays which are previously not available (ibid).Evolutionary psychology has been particularly valuable in the discipline of human sexuality, where people’s understanding lingers behind thesignificance of a discipline that influences all of humanity.

Biology Practical on Cells

The final magnification of the details of specimen under observation is the product of both the eye-piece, and objective lenses (Caprette, 2005).For one to be able to note the details of the specimen, staining is necessary. Different substances will absorb light differently, thus transmit light in different proportions. The difference in light transmission through the different parts due to staining makes the isolation of details possible. The extent to which a microscope differentiates fine details in the specimen is called the resolution. In the light microscope, the resolution can be obtained as below:The resolution becomes smaller as the resolution of the microscope improves. The value ‘n’ is increased by using a drop of oil. The drop is placed between the objective lens and the specimen. With this type of microscope, the resolution ranges between 0.2µm and 200nm. This is because the λ of light is 450nm (Karp, 2009, p. 718).The intention of this part of the practical is to obtain cells from the cheek, and observe the cell structure under a light microscope. The staining was done using eosin, and haematoxylin dyes. This procedure was done while wearing a glove since it involved coming into contact with human fluid, specifically saliva. Wearing gloves was a safety measure that is a procedural requirement when dealing with specimen from animals.5. The contents of the tube were poured into a Petri dish. The root tips were carefully picked out using a forceps and placed in an Eppendorf tube which contained aceto-orcein. The mixture was left in the dark for 10 minutes.7. The softened root tip, which by now had softened, was squashed. It was then stained by lightly tapping lightly on the coverslip using a pencil. On doing this the root tip spread out as a pink mass.Enzymes are proteins that are distributed in all cellular compartments. In definition, enzymes are proteins which catalyze biological processes.

Evolutionary Psychology and Attraction

Sociobiology, with its focus on biological accounts of evident social facts, has developed into evolutionary psychology, with its stress on the process of the evolution of the brain, and the extent of influence of people’s desire to survive and to multiply their genes into the next generations to their present behavior and conduct (ibid).Sociobiology or evolutionary psychology both in the modern age apply scientific methods of investigation, and subject raw data to quantitative analysis. Any science makes use of speculations, theory, and others. However, these are applied in the service of an empirical framework, and the aged criticisms are nowadays primarily incorrect. The concept of evolution is the adhesive in biology. Carrying this concept into psychology has offered countless new ideas and insights (ibid). Evolutionary psychology is one of the most essential new assumptions of the contemporary times, making use of Darwin’s ideas on evolution and natural selection to the psychological study of humans.There has been, as people think, a paradigm shift in psychology, such that several phenomena clarified in terms of social causation, or impossible to explain at all, are now clarified in the evolutionary psychology discipline. Hence, evolutionary, biological clarifications have turned out to be more often in psychology, while explanations in terms of social psychology, education, or culture have turned out to be observed as less practical (Mortola, 1999). Genes and the environment function together, hence these other regions are not declined, and they merely are not applied as much anymore as the foremost explanation of phenomena. Using the concept of human sexuality, this paper will show how the innovated evolutionary psychology explains significant ideas nowadays which are previously not available (ibid).Evolutionary psychology has been particularly valuable in the discipline of human sexuality, where people’s understanding lingers behind thesignificance of a discipline that influences all of humanity.

Biology Practical on Cells

The final magnification of the details of specimen under observation is the product of both the eye-piece, and objective lenses (Caprette, 2005).For one to be able to note the details of the specimen, staining is necessary. Different substances will absorb light differently, thus transmit light in different proportions. The difference in light transmission through the different parts due to staining makes the isolation of details possible. The extent to which a microscope differentiates fine details in the specimen is called the resolution. In the light microscope, the resolution can be obtained as below:The resolution becomes smaller as the resolution of the microscope improves. The value ‘n’ is increased by using a drop of oil. The drop is placed between the objective lens and the specimen. With this type of microscope, the resolution ranges between 0.2µm and 200nm. This is because the λ of light is 450nm (Karp, 2009, p. 718).The intention of this part of the practical is to obtain cells from the cheek, and observe the cell structure under a light microscope. The staining was done using eosin, and haematoxylin dyes. This procedure was done while wearing a glove since it involved coming into contact with human fluid, specifically saliva. Wearing gloves was a safety measure that is a procedural requirement when dealing with specimen from animals.5. The contents of the tube were poured into a Petri dish. The root tips were carefully picked out using a forceps and placed in an Eppendorf tube which contained aceto-orcein. The mixture was left in the dark for 10 minutes.7. The softened root tip, which by now had softened, was squashed. It was then stained by lightly tapping lightly on the coverslip using a pencil. On doing this the root tip spread out as a pink mass.Enzymes are proteins that are distributed in all cellular compartments. In definition, enzymes are proteins which catalyze biological processes.

Weeks56ScienceandReligionGlossary

RELIGION AND SCIENCE: IMPORTANT TERMSConflict thesis—The thesis that science and religion have experienced a long history of conflict or warfare.[1] Also known as the “military metaphor” for or the “warfare model” of the relationship between science and religion.[2]Natural Philosophy—The name for science in the ancient, medieval, and early modern periods; the branch of philosophy that sought to gain knowledge of physical reality and the material causes of things.[3]Scientific Revolution—The period from the 1500s through the 1700s, when medieval natural philosophy was transformed into early modern science.[4]Modern Scientific Method—Elements in modern scientific method include the notions1. that all hypotheses, theories, or truth-claims must be tested empirically;2. that the testing must be public, open to criticism by opponents;3. that there is no point at which the testing has been completed once and for all;4. that all scientific truth-claims are therefore tentative, at least in principle.Scientism—The idea that any question that can be answered at all can best be answered by science; a view that denies that science has limits.[5]Fideism—A view that denies that there is a legitimate place for science and reason within the content of religious faith and denies that religious faith has limits.Epistemology—The branch of philosophy that studies the nature and limits of knowledge, and the justification of belief.[6]The God of the Gaps—the mistake of using God as an explanation of what is currently scientific unknown; using God as an explanation when there are empirical “gaps” in in our knowledge. This is not scientifically or theologically a valid move. The Anthropic Principle—“The assertion that the physical constants of the early universe were delicately balanced or ‘fine-tuned’: if they had even slightly different values, carbon-based life and our presence as intelligent observers would not have been possible.”[7] Theory—“a coherent statement that provides an explanation for certain phenomena. It is a well-substantiated explanation of some aspect of the natural world, crafted by pulling together observed facts and known laws and interpreting them with an insightful hypothesis.”  Thus, one should say not that one “believes” in evolution, but that one “accepts it as demonstrated.”The Big Bang Theory—“In 1929, Edwin Hubble, examining the ‘red shift’ of light from distant nebulae [interstellar clouds of dust, hydrogen, helium and other ionized gases], formulated Hubble’s Law: the velocity of recession of a nebula is proportional to its distance from us. Space itself, not just object in space, is everywhere expanding. Extrapolating backward in time, the universe seems to be expanding from a common origin about fifteen billion years ago.”[8]Biblical Fundamentalism—“An approach to biblical interpretation that asserts the Bible is without error; every word must be taken in its ‘natural sense.’ Such an approach dismisses historical and literary approaches to interpreting the Bible.”[9]The Historical-Critical Method of Biblical Interpretation—“A methodology used to interpret the Bible that came into wide use in the 19thcentury. This method recognizes the Bible as not only inspired by God but also as a collection of ancient documents composed by numerous human beings over millennia. This method applies historical, literary, and philological analysis to the biblical text to establish what it meant in order to ask what the text can mean to believers today.”[10]Myth—“From the Greek word mythos or ‘story.’ When used in connection with biblical stories, it connotes stories that are created to express the deepest truths of what it means to be a human being, such as the stories found in Gn 1 and Gn 2-3.”[11]Creationism—“All theists accept the doctrine of creation, but the term ‘creationism’ today usually refers to the beliefs of biblical literalists who reject evolutionary biology.”[12]“Young earth creationists”—6,000 years ago God made the earth in 6 literal calendar days“Old earth creationists”—Earth-history is 4.5 billion years long, but every species exists because of God’s “special creation” rather than through natural processes Adam and Eve were created perfectly in the Garden of Eden.“Scientific Creationism”—“The biblical creation stories give us a more reliable scientific explanation than we can get from Darwinian biology.” They take the Bible to be scientifically authoritative because if it is literally inerrant, it cannot contradict science. Darwinism and creationism are two different scientific theories.Intelligent Design—“the argument that the structures, features, organs, and biochemical pathways that we find in living cells are so complex that they could not have been produced by natural processes such as evolution and that they would require the intervention of an intelligent designer outside of nature to bring them into existence.”  This idea is rejected by most scientists. It is an argument used by many creationists.[1]Joshua Moritz, Science and Religion: Beyond Warfare and Toward Understanding, p. 292[2]Colin A. Russell, “The Conflict of Science and Religion” in Science and Religion: A Historical Introduction, ed. by Gary B. Ferngren, p. 3.[3]Moritz, p. 295.[4]Moritz, p. 296.[5]Moritz, p. 296.[6]Moritz, p. 293.[7]Ian Barbour, Religion and Science: Historical and Contemporary Issues, p. 357.[8]Ian Barbour, Religion and Science: Historical and Contemporary Issues, p. 195.[9]Kathleen Birge, et al. Genesis, Evolution, and the Search for a Reasoned Faith, p. 38.[10]Birge, et al., p. 38.[11]Birge, et al., p. 39.[12]John F. Haught, Responses to 101 Questions on God and Evolution, p. 71

Unit2 2Sociology

Ch. 44-1Why Is Socialization Important Around the Globe?LO1Debatethe extent to which people would become human beings without adequate socialization.Socializationis the lifelong process of social interaction through which individuals acquire a self-identity and the physical, mental, and social skills needed for survival in society (Figure 4.1). It is the essential link between the individual and society because it helps us become aware of ourselves as members of the larger groups and organizations of which we are a part. Socialization also helps us to learn how to communicate with other people and to have knowledge of how other people expect us to behave in a variety of social settings. Briefly stated, socialization enables us to develop our human potential and to learn the ways of thinking, talking, and acting that are necessary for social living.Figure4.1The kind of person we become depends greatly on the people who surround us. How will this boy’s life be shaped by his close and warm relationship with his mother?Christopher Futcher/iStockphoto.comWhen do you think socialization is most important? Socialization is the most crucial during childhood because it is essential for the individual’s survival and for human development. The many people who met the early material and social needs of each of us were central to our establishing our own identity. Can you identify some of the people in your own life who were the most influential in your earliest years of social development? During the first three years of our life, we begin to develop both a unique identity and the ability to manipulate things and to walk. We acquiresophisticated cognitive tools for thinking and for analyzing a wide variety of situations, and we learn effective communication skills. In the process we begin a socialization process that takes place throughout our lives and through which we also have an effect on other people who watch us.What does socialization do for us beyond the individual level? Socialization is essential for the survival and stability of society. Members of a society must be socialized to support and maintain the existing social structure. From a functionalist perspective, individual conformity to existing norms is not taken for granted; rather, basic individual needs and desires must be balanced against the needs of the social structure. The socialization process is most effective when people conform to the norms of society because they believe that doing so is the best course of action. Socialization enables a society to “reproduce” itself by passing on its culture from one generation to the next.How does socialization differ across cultures and ways of life? Although the techniques used to teach newcomers the beliefs, values, and rules of behavior are somewhat similar in many nations, thecontentof socialization differs greatly from society to society. How people walk, talk, eat, make love, and wage war are all functions of the culture in which they are raised. At the same time, we are also influenced by our exposure to subcultures of class, race, ethnicity, religion, and gender. In addition, each of us has unique experiences in our family and friendship groupings. The kind of human being that we become depends greatly on the particular society and social groups that surround us at birth and during early childhood. What we believe about ourselves, our society, and the world does not spring full-blown from inside ourselves; rather, we learn these things from our interactions with others. What examples can you think of from your own experiences with your family and other close associates?4-1aHuman Development: Biology and SocietyWhat does it mean to be “human”? To be human includes being conscious of ourselves as individuals, with unique identities, personalities, and relationships with others. As humans, we have ideas, emotions, and values. We have the capacity to think and to make rational decisions. But what is the source of “humanness”? Are we born with these human characteristics, or do we develop them through our interactions with others?Have you ever thought about what you were like when you were first born? When we are born, we are totally dependent on others for our survival. We cannot turn ourselves over, speak, reason, plan, or do many of the things that are associated with being human. Although we can nurse, wet, and cry, most small mammals can also do those things. As discussed inChapter 3, we humans differ from nonhuman animals because we lack instincts and must rely on learning for our survival. Human infants have the potential to develop human characteristics if they are exposed to an adequate socialization process.Do you think we are more the product of our biological inheritance or the people we are around? Every human being is a product of biology, society, and personal experiences—that is, of heredity and environment or, in even more basic terms, “nature” and “nurture.” How much of our development can be explained by socialization? How much by our genetic heritage? Sociologists focus on how humans design their own culture and transmit it from generation to generation through socialization. By contrast, sociobiologists assert that nature, in the form of our genetic makeup, is a major factor in shaping human behavior.Sociobiologyis the systematic study of “social behavior from a biological perspective” (Wilson and Wilson, 2007: 328). According to the zoologist Edward O. Wilson, who pioneered sociobiology, genetic inheritance underlies many forms of social behavior, such as war and peace, envy of and concern for others, and competition and cooperation. Most sociologists disagree with the notion that biological principles can be used to explain all human behavior. Obviously, however, some aspects of our physical makeup—such as eye color, hair color, height, and weight—are largely determined by our heredity.How important is social influence (“nurture”) in human development? There is hardly a single behavior that is not influenced socially. Except for simple reflexes, most human actions are social, either in their causes or in theirconsequences. Even solitary actions such as crying or brushing our teeth are ultimately social. We cry because someone has hurt us. We brush our teeth because our parents (or dentist) told us it was important. Social environment probably has a greater effect than heredity on the way we develop and the way we act. However, heredity does provide the basic material from which other people help to mold an individual’s human characteristics.How are our biological and emotional needs met, and how are they related? Children whose needs are met in settings characterized by affection, warmth, and closeness see the world as a safe and comfortable place and see other people as trustworthy and helpful. By contrast, infants and children who receive less-than-adequate care or who are emotionally rejected or abused often view the world as hostile and have feelings of suspicion and fear.4-1bProblems Associated with Social Isolation and MaltreatmentSocial environment, then, is a crucial part of an individual’s socialization. Even nonhuman primates such as monkeys and chimpanzees need social contact with others of their species in order to develop properly. As we will see, appropriate social contact is even more important for humans.Isolation and Nonhuman PrimatesResearchers have attempted to demonstrate the effects of social isolation on nonhuman primates raised without contact with others of their own species. In a series of laboratory experiments, the psychologists Harry and Margaret Harlow (1962, 1977) took infant rhesus monkeys from their mothers and isolated them in separate cages. Each cage contained two nonliving “mother substitutes” made of wire, one with a feeding bottle attached and the other covered with soft terry cloth but without a bottle (seeFigure 4.2). The infant monkeys instinctively clung to the cloth “mother” and would not abandon it until hunger drove them to the bottle attached to the wire “mother.” As soon as they were full, they went back to the cloth “mother” seeking warmth, affection, and physical comfort.Figure4.2As Harry and Margaret Harlow discovered, humans are not the only primates that need contact with others. Deprived of its mother, this infant monkey found a substitute.Martin Rogers/The Image Bank/Getty ImagesThe Harlows’ experiments show the detrimental effects of isolation on nonhuman primates. When the young monkeys were later introduced to other members of their species, they cringed in the corner. Having been deprived of social contact during their first six months of life, they never learned how to relate to other monkeys or to become well-adjusted adults—they were fearful of or hostile toward other monkeys (Harlow and Harlow, 1962, 1977).Because humans rely more heavily on social learning than do monkeys, the process of socialization is even more important for us.Isolated ChildrenOf course, sociologists would never place children in isolated circumstances so that they could observe what happened to them. However, some cases have arisen in which parents or other caregivers failed to fulfill their responsibilities, leaving children alone or placing them in isolated circumstances. From analysis of these situations, social scientists have documented cases in which children were deliberately raised in isolation. A look at the lives of two children who suffered such emotional abuse provides important insights into the significance of a positive socialization process and the negative effects of social isolation.AnnaBorn in 1932 in Pennsylvania to an unmarried, mentally impaired woman, Anna was an unwanted child. She was kept in an attic-like room in her grandfather’s house. Her mother, who worked on the farm all day and often went out at night, gave Anna just enough care to keepher alive; she received no other care. Sociologist Kingsley Davis (1940) described Anna’s condition when she was found in 1938:[Anna] had no glimmering of speech, absolutely no ability to walk, no sense of gesture, not the least capacity to feed herself even when the food was put in front of her, and no comprehension of cleanliness. She was so apathetic that it was hard to tell whether or not she could hear. And all of this at the age of nearly six years.When she was placed in a special school and given the necessary care, Anna slowly learned to walk, talk, and care for herself. Just before her death at the age of ten, Anna reportedly could follow directions, talk in phrases, wash her hands, brush her teeth, and try to help other children (Davis, 1940).GenieAbout three decades later, Genie was found in 1970 at the age of thirteen (Figure 4.3). She had been locked in a bedroom alone, alternately strapped down to a child’s potty chair or straitjacketed into a sleeping bag, since she was twenty months old. She had been fed baby food and beaten with a wooden paddle when she whimpered. She had not heard the sounds of human speech because no one talked to her and there was no television or radio in her room (Curtiss, 1977; Pines, 1981). Genie was placed in a pediatric hospital, where one of the psychologists described her condition:At the time of her admission she was virtually unsocialized. She could not stand erect, salivated continuously, had never been toilet-trained and had no control over her urinary or bowel functions. She was unable to chew solid food and had the weight, height and appearance of a child half her age. (Rigler, 1993: 35)Figure4.3A victim of extreme child abuse, Genie was isolated from human contact and tortured until she was rescued at the age of thirteen. What are the consequences to children of isolation and physical abuse, as contrasted with social interaction and parental affection? Sociologists emphasize that the social environment is a crucial part of an individual’s socialization.Bettman/CorbisIn addition to her physical condition, Genie showed psychological traits associated with neglect, as described by one of her psychiatrists:If you gave [Genie] a toy, she would reach out and touch it, hold it, caress it with her fingertips, as though she didn’t trust her eyes. She would rub it against her cheek to feel it. So when I met her and she began to notice me standing beside her bed, I held my hand out and she reached out and took my hand and carefully felt my thumb and fingers individually, and then put my hand against her cheek. She was exactly like a blind child. (Rymer, 1993: 45)Extensive therapy was used in an attempt to socialize Genie and develop her language abilities (Curtiss, 1977; Pines, 1981). These efforts met with limited success: In the 1990s, Genie was living in a board-and-care home for adults with intellectual disabilities (see Angier, 1993; Rigler, 1993; Rymer, 1993). From 2008, when the latest available reports on Genie were released by the news media, we know that she was 51 and living in a foster home where she had experienced further regression and was unable to speak (James, 2008). No further information about her is currently available.Why do we discuss children who have been the victims of maltreatment when we are thinking about the socialization process? Because cases like this are important to our understanding of the socialization process and show the importance of the process. These cases also demonstrate how detrimental that social isolation and neglect can be to the well-being of people. Among other things, for children to experience proper grammatical development, they need linguistic stimulation from other people. If children do not hear language, they are unable to speak in sentences.Child MaltreatmentWhat do the termschild maltreatmentandchild abusemean to you? When asked what constitutes child maltreatment, many people first think of cases that involve severe physical injuries or sexual abuse. However, neglect is the most frequent form of child maltreatment (Mattingly and Walsh, 2010). Child neglectoccurs when children’s basic needs—including emotional warmth and security, adequate shelter, food, health care, education, clothing, and protection—are not met, regardless of cause (Mattingly and Walsh, 2010). Neglect often involves acts of omission (where parents or caregivers fail to provide adequate physical or emotional care for children) rather than acts of commission (such as physical or sexual abuse). Neglect is the most common type of maltreatment among children under age eighteen (seeFigure 4.4). Of course, what constitutes child maltreatment differs from society to society.Figure4.4Types of Maltreatment Among Children Under Age 18**Does not add up to 100 percent because a child may have suffered from multiple forms of maltreatment and was counted once for each maltreatment type.Source: U.S. Department of Health and Human Services, Children’s Bureau, 2015.Social Isolation and LonelinessUp to this point, we have primarily looked at the effects of isolation on children in their formative years. However, social isolation and loneliness are central issues for persons across all age categories. In the twenty-first century, medical and social researchers continually produce new research documenting that lack of interaction and ongoing learning from others is problematic for everyone. Although we often think that we are more connected than people were in the past and that we have more “friends” than would have been possible for them (because of Facebook, Twitter, Instagram, Foursquare, Pinterest, and other social media sites), the reality is that many people are lonely and have few people to confide in. One study found that 20 percent of all individuals are, at any given time, unhappy because of social isolation (Cacioppo and Hawkley, 2003). According to one study, “People are so embarrassed about being lonely that no one admits it. Loneliness is stigmatized, even though everyone feels it at one time or another” (Seligman, 2009).Living alone does not necessarily equal being lonely; people experience loneliness in different ways, and some people are more sensitive to social isolation than others. This is why the socialization process of learning how to interact with other people is important. Communicating with other people and learning from them links us to a larger social world and is energizing for us. Gerontologists who study aging and the issues associated with this process are the first to tell us that older individuals are among the most likely to be socially isolated because of the structure of contemporary families and the greater likelihood that one spouse (typically the wife) will outlive the other partner by a good number of years. We will look into this issue in greater detail inChapter 12, “Aging and Inequality Based on Age.”4-2Social Psychological Theories of Human DevelopmentOver the past hundred years, a variety of psychological and sociological theories have been developed not only to explain child abuse but also to describe how a positive process of socialization occurs. Although these are not sociological theories, it is important to be aware of the contributions of Freud, Piaget, Kohlberg, and Gilligan because knowing about them provides us with a framework for comparing various perspectives on human development.4-2aFreud and the Psychoanalytic PerspectiveThe basic assumption in Sigmund Freud’s (1924) psychoanalytic approach is that behavior and personality originate from unconscious forces within individuals. Freud (1856–1939), who is known as the founder of psychoanalytic theory, developed his major theories in the Victorian era, when biological explanations of human behavior were prevalent (Figure 4.5). For example, Freud based his ideas on the belief that people have two basic tendencies: the urge to survive and the urge to procreate.Figure4.5Sigmund Freud, founder of the psychoanalytic perspective.Mary Evans/The Image WorksAccording to Freud (1924), human development occurs in three states that reflect different levels of the personality, which he referred to as theid, ego, andsuperego.Theidis the component of personality that includes all of the individual’s basic biological drives and needs that demand immediate gratification. For Freud, the newborn child’s personality is all id, and from birth the child finds that urges for self-gratification—such as wanting to be held, fed, or changed—are not going to be satisfied immediately. However, id remains with people throughout their life in the form ofpsychic energy, the urges and desires that account for behavior.By contrast, the second level of personality—theego—develops as infants discover that their most basic desires are not always going to be immediately met. Theegois the rational, reality-oriented component of personality that imposes restrictions on the innate pleasure-seeking drives of the id. The ego channels the desire of the id for immediate gratification into the most advantageous direction for the individual. The third level of personality—the superego—is in opposition to both the id and the ego. Thesuperego, or conscience, consists of the moral and ethical aspects of personality. It is first expressed as the recognition of parental control and eventually matures as the child learns that parental control is a reflection of the values and moral demands of the larger society. When a person is well adjusted, the ego successfully manages the opposing forces of the id and the superego.Figure 4.6illustrates Freud’s theory of personality.Figure4.6Freud’s Theory of PersonalityThis illustration shows how Freud might picture a person’s internal conflict over whether to commit an antisocial act such as stealing a candy bar. In addition to dividing personality into three components, Freud theorized that our personalities are largely unconscious—hidden from our normal awareness. To dramatize his point, Freud compared conscious awareness (portions of the ego and superego) to the visible tip of an iceberg. Most of personality—including the id, with its raw desires and impulses—lies submerged in our subconscious.4-2bPiaget and Cognitive DevelopmentJean Piaget (1896–1980), a Swiss psychologist, was a pioneer in the field of cognitive (intellectual) development (Figure 4.7). Cognitive theorists are interested in how people obtain, process, and use information—that is, in how we think. Cognitive development relates to changes over time in how we think.Figure4.7Jean Piaget, a pioneer in the field of cognitive development.AFP/Getty ImagesPiaget (1954) believed that in each stage of development (from birth through adolescence), children’s activities are governed by their perception of the world around them. His four stages of cognitive development are organized around specific tasks that, when mastered, lead to the acquisition of new mental capacities, which then serve as the basis for the next level of development. Piaget emphasized that all children must go through each stage in sequencebefore moving on to the next one, although some children move through them faster than others.1. Sensorimotor stage(birth to age two). During this period, children understand the world only through sensory contact and immediate action because they cannot engage in symbolic thought or use language. Toward the end of the second year, children comprehendobject permanence;in other words, they start to realize that objects continue to exist even when the items are out of sight.2. Preoperational stage(age two to seven). In this stage, children begin to use words as mental symbols and to form mental images. However, they are still limited in their ability to use logic to solve problems or to realize that physical objects may change in shape or appearance while still retaining their physical properties (seeFigure 4.8).Figure4.8The Preoperational StagePsychologist Jean Piaget identified four stages of cognitive development, including the preoperational stage, in which children have limited ability to realize that physical objects may change in shape or appearance. Piaget showed children two identical beakers filled with the same amount of water. After the children agreed that both beakers held the same amount of water, Piaget poured the water from one beaker into a taller, narrower beaker and then asked them about the amounts of water in each beaker. Those still in the preoperational stage believed that the taller beaker held more water because the water line was higher than in the shorter, wider beaker.Tony Freeman/PhotoEdit3. Concrete operational stage(age seven to eleven). During this stage, children think in terms of tangible objects and actual events. They can draw conclusions about the likely physical consequences of an action without always having to try the action out. Children begin to take the role of others and start to empathize with the viewpoints of others.4. Formal operational stage(age twelve through adolescence). By this stage, adolescents are able to engage in highly abstract thought and understand places, things, and events they have never seen. They can think about the future and evaluate different options or courses of action.4-2cKohlberg and the Stages of Moral DevelopmentLawrence Kohlberg (1927–1987) elaborated on Piaget’s theories of cognitive reasoning by conducting a series of studies in which children, adolescents, and adults were presented with moral dilemmas that took the form of stories. Based on his findings, Kohlberg (1969, 1981) classified moral reasoning into three sequential levels:1. Preconventional level(age seven to ten). Children’s perceptions are based on punishment and obedience. Evil behavior is that which is likely to be punished; good conduct is based on obedience and avoidance of unwanted consequences.2. Conventional level(age ten through adulthood). People are most concerned with how they are perceived by their peers and with how one conforms to rules.3. Postconventional level(few adults reach this stage). People view morality in terms of individual rights; “moral conduct” is judged by principles based on human rights that transcend government and laws.4. 4-2dGilligan’s View on Gender and Moral Development5. Psychologist Carol Gilligan (b. 1936) noted that both Piaget and Kohlberg did not take into account how gender affects the process of social and moral development. According to Gilligan (1982), Kohlberg’s model was developed solely on the basis of research with male respondents, who often have different views from women on morality. Gilligan believes that men become more concerned with law and order but that women tend to analyze social relationships and the social consequences of behavior. Gilligan argues that men are more likely to useabstract standardsof right and wrong when making moral decisions, whereas women are more likely to be concerned about theconsequencesof behavior. Does this constitute a “moral deficiency” on the part of either women or men? Not according to Gilligan, who believes that people make moral decisions according to both abstract principles of justice and principles of compassion and care.6. 4-3Sociological Theories of Human Development7. LO28. Discussthe sociological perspective on human development, emphasizing the contributions of Charles Horton Cooley and George Herbert Mead.9. Although social scientists acknowledge the contributions of social–psychological explanations of human development, sociologists believe that it is important to bring a sociological perspective to bear on how people develop an awareness of self and learn about the culture in which they live. Let’s look at symbolic interactionist, functional, and conflict approaches to describing the socialization process and its outcomes.4-3aSymbolic Interactionist Perspectives on SocializationAccording to a symbolic interactionist approach to socialization, we cannot form a sense of self or personal identity without intense social contact with others. How do we develop ideas about who we are? How do we gain a sense of self? The self represents the sum total of perceptions and feelings that an individual has of being a distinct, unique person—a sense of who and what one is. When we speak of the “self,” we typically use words such asI, me, my, mine, andmyself(Cooley, 1998/1902). This sense of self (also referred toself-concept) is not present at birth; it arises in the process of social experience.Self-conceptis the totality of our beliefs and feelings about ourselves. Four components make up our self-concept:(1)the physical self (“I am tall”),(2)the active self (“I am good at soccer”),(3)the social self (“I am nice to others”), and(4)the psychological self (“I believe in world peace”).Between early and late childhood, a child’s focus tends to shift from the physical and active dimensions of self toward the social and psychological aspects. Self-concept is the foundation for communication with others; it continues to develop and change throughout our lives.Ourself-identityis our perception about what kind of person we are and our awareness of our unique identity. Self-identity emerges when we ask the question “Who am I?” Factors such as individuality, uniqueness, and personal characteristics and personality are components of self-identity. As we have seen, socially isolated children do not have typical self-identities because they have had no experience of “humanness.” According to symbolic interactionists, we do not know who we are until we see ourselves as we believe that others see us. The perspectives of symbolic interactionists Charles Horton Cooley and George Herbert Mead help us understand how our self-identity is developed through our interactions with others.Cooley: Looking-Glass SelfCharles Horton Cooley (1864–1929) was one of the first U.S. sociologists to describe how we learn about ourselves through social interaction with other people. Cooley used the concept of thelooking-glass selfto describe how the self emerges. Thelooking-glass selfrefers to the way in which a person’s sense of self is derived from the perceptions of others. Our looking-glass self is based on our perception ofhowother people think of us (Cooley, 1998/1902). AsFigure 4.9shows, the looking-glass self is a self-concept derived from a three-step process:1. We imagine how our personality and appearance will look to other people.2. We imagine how other people judge the appearance and personality that we think we present.3. We develop a self-concept. If we think the evaluation of others is favorable, our self-concept is enhanced. If we think the evaluation is unfavorable, our self-concept is diminished. (Cooley, 1998/1902)Figure4.9How the Looking-Glass Self WorksBecause the looking-glass self is based on how weimagineother people view us, we may develop self-concepts based on an inaccurate perception of what other individuals think about us. Consider, for example, the individual who believes that other people see him or her as “fat” when, in actuality, he or she is a person of an average height, weight, and build. The consequences of such a false perception may lead to excessive dieting or health problems such as anorexia, bulimia, and other eating disorders.Mead: Role-Taking and Stages of the SelfGeorge Herbert Mead (1863–1931) extended Cooley’s insights by linking the idea of self-concept torole-taking—the process by which a person mentally assumes the role of another person or group in order to understand the world from that person’s or group’s point of view. Role-taking often occurs through play and games, as children try out different roles (such as being mommy, daddy, doctor, or teacher) and gain an appreciation of them. First, people come to take the role of the other (role-taking). By taking the roles of others, the individual hopes to ascertain the intention or direction of the acts of others. Then the person begins to construct his or her own roles (role-making) and to anticipate other individuals’ responses. Finally, the person plays at her or his particular role (role-playing).According to Mead (1934), children in the early months of life do not realize that they are separate from others. However, they do begin early on to see a mirrored image of themselves in others. Shortly after birth, infants start to notice the faces of those around them, especially the significant others, whose faces start to have meaning because they are associated with experiences such as feeding and cuddling.Significant othersare those persons whose care, affection, and approval are especially desired and who are most important in the development of the self. Gradually, we distinguish ourselves from our caregivers and begin to perceive ourselves in contrast to them. As we develop language skills and learn to understand symbols, we begin to develop a self-concept. When we can represent ourselves in our minds as objects distinct from everything else, our self has been formed.As Mead (1934) points out, the self has two sides—the “me” and the “I.” The “me” is what is learned by interaction with others in the larger social environment; it is the organized set of attitudes of others that an individual assumes. The “me” is the objective element of the self, which represents an internalization of the expectations and attitudes of others and the individual’s awareness of those demands. By contrast, the “I” is the person’s individuality—it is the response of the person to the attitudes of other individuals. We might think of the “me” as the social self and the “I” as the response to the “me.” According to Mead, the “I” develops first, and the “me” takes form during the three stages of self-development (Figure 4.10):1. During thepreparatory stage, up to about age three, interactions lack meaning, and children largely imitate the people around them, particularly parents and other family members. At this stage, children are preparing for role-taking.2. In theplay stage, from about age three to five, children learn to use language and other symbols, thus enabling them to pretend to take the roles of specific people. At this stage, they begin to see themselves in relation to others, but they do not see role-taking as something they have to do.3. During thegame stage, which begins in the early school years, children understand not only their own social position but also the positions of others around them. In contrast to play, games are structured by rules, are often competitive, and involve a number of other “players.” At this time, children become concerned about the demands and expectations of others and of the larger society.Figure4.10According to sociologist George Herbert Mead, the self develops through three stages. In the preparatory stage, children imitate others; in the play stay, children pretend to take the roles of specific people; and in the game stage, children become aware of the “rules of the game” and the expectations of others.Peter Cade/The Image Bank/Getty Images; Stella/Getty Images; Matt Lewis—The FA/Getty ImagesMead’s concept of thegeneralized otherrefers to the child’s awareness of the demands and expectations of the society as a whole or of the child’s subculture. According to Mead, the generalized other is evident when a person takes into account other people and groups when he or she speaks or acts. In sum, both the “I” and the “me” are needed to form the social self. The unity of the two (the “generalized other”) constitutes the full development of the individual and a more thorough understanding of the social world.More-Recent Symbolic Interactionist PerspectivesSymbolic interactionist approaches emphasize that socialization is a collective process in which children are active and creative agents, not just passive recipients of the socialization process. From this view, childhood is asocially constructedcategory. As children acquire language skills and interact with other people, they begin to construct their own shared meanings. Sociologist William A. Corsaro (2011) refers to this as the “orb web model,” whereby the cultural knowledge that children possess consists not only of beliefs found in the adult world but also of unique interpretations from the children’s own peer culture. According to Corsaro, children create and share their ownpeer culture, which is an established set of activities, routines, and beliefs that are in some ways different from adult culture. This peer culture emerges through interactions as children “borrow” from theadult culture but transform it so that it fits their own situation. In fact, according to Corsaro, peer culture is the most significant arena in which children and young people acquire cultural knowledge.4-3bFunctionalist Perspectives on SocializationAs discussed inChapter 1, functionalist theorists such as Talcott Parsons and Robert Merton saw socialization as the process by which individuals internalize social norms and values. They believed that socialization is important to societies as well as to individuals because social institutions must be maintained and preserved for a nation to survive. For these institutions to be efficient, individuals must play their roles appropriately, or dysfunctions will occur. Simply stated, the socialization process plays an integral part in teaching the next generation, as well as new arrivals, about how to conform to the rules of the game, and this keeps the society functioning properly. As a result of adequate socialization, people come to support a society that is stable and orderly. Individuals learn to accept the values, beliefs, and behavioral expectations that keep society, and sometimes the larger global community, functioning effectively.Some functionalist theorists identify three stages of socialization:Primary socializationrefers to the process of learning that begins at birth and occurs in the home and family; by contrast,secondary socializationrefers to the process of learning that takes place outside the home—in settings such as schools, religious organizations, and the workplace—and helps individuals learn how to act in appropriate ways in various situations. Secondary socialization often occurs when we are teenagers and young adults.Tertiary socializationtakes place when adults move into new settings where they must accept certain ideas or engage in specific behaviors that are appropriate to that specific setting. (SeeFigure 4.11.) For example, older persons entering a retirement community often have to internalize new social norms and values that are appropriate to the setting in which they now reside. From a functionalist approach, problems in the socialization process contribute not only to individual concerns but also to larger societal issues, such as high rates of crime and poverty, school dropouts and failures, and family discord.Figure4.11Some theorists identify three stages of socialization: primary, secondary, and tertiary. At what stage might socialization be occurring for the people working together in this photo?© Shots Studio/Shutterstock.com4-3cConflict Perspectives on SocializationBased on an assumption that groups in society are engaged in a continuous power struggle for control of scarce resources, conflict theorists stress that socialization contributes to “false consciousness”—a lack of awareness and a distorted perception of the reality of class as it affects all aspects of social life. As a result, socialization reaffirms and reproduces the class structure in the next generation rather than challenging existing conditions. For example,children in low-income families may be unintentionally socialized to believe that acquiring an education and aspiring to lofty ambitions are pointless because of existing economic conditions in the family. By contrast, middle- and upper-income families typically instill ideas of monetary and social success in children. As discussed later, schools may also provide different experiences to children depending on their gender, social class, racial–ethnic background, and other factors. This chapter’sConcept Quick Reviewsummarizes the major theories of human development and socialization.Concept Quick Review Psychological and Sociological Theories of Human Development and Socialization Social Psychological Theories Freud’s psychoanalytic perspective Piaget’s cognitive development Children go through four stages of cognitive (intellectual) development, moving from understanding only through sensory contact to engaging in highly abstract thought. Kohlberg’s stages of moral development People go through three stages of moral development, from avoidance of unwanted consequences to viewing morality based on human rights. Gilligan: gender and moral development Women go through stages of moral development from personal wants to the greatest good for themselves and others. Symbolic Interactionist Theories Cooley’s looking-glass self A person’s sense of self is derived from his or her perception of how others view him or her. Mead’s three stages of self-development In the preparatory stage, children prepare for role-taking. In the play stage, they pretend to take the roles of specific people. In the game stage, they learn to take into account the deman 4-4Agents of SocializationAgents of socializationare the persons, groups, or institutions that teach us what we need to know in order to participate in society. We are exposed to many agents of socialization throughout our lifetime; in turn, we have an influence on those socializing agents and organizations. In this section we look at the most pervasive agents of socialization in childhood—the family, the school, peer groups, and the mass media.4-4aThe FamilyLO3Contrastfunctionalist and conflict theorists’ perspectives on the roles that families play in the socialization process.The family is the most important agent of socialization in all societies. From our infancy onward, our families transmit cultural and social values to us (Figure 4.12). As discussed later in this book, families vary in size and structure. Some families consist of two parents and their biological children, whereas others consist of a single parent and one or more children. Still other families reflect changing patterns of divorce and remarriage, and an increasing number are made up of same-sex partners and their children. Over time, patterns have changed in some two-parent families so that fathers, rather than mothers, are the primary daytime agents of socialization for their young children.Figure4.12As this chess game attended by several generations of family members illustrates, socialization enables society to “reproduce” itself.© wavebreakmedia/Shutterstock.comTheorists using a functionalist perspective emphasize that families serve important functions in society because they are the basis for the procreation and socialization of children. Most of us form an emerging sense of self andacquire most of our beliefs and values within the family context. We also learn about the larger dominant culture (including language, attitudes, beliefs, values, and norms) and the primary subcultures to which our parents and other relatives belong.Families are also the primary source of emotional support. Ideally, people receive love, understanding, security, acceptance, intimacy, and companionship within families. The role of the family is especially significant because young children have little social experience beyond the family’s boundaries; they have no basis for comparing or evaluating how they are treated by their own family.To a large extent, the family is where we acquire our specific social position in society. From birth, we are a part of the specific racial, ethnic, class, religious, and regional subcultural grouping of our family. Many parents socialize their children somewhat differently based on race, ethnicity, and class. Some families instruct their children about the unique racial–ethnic and/or cultural backgrounds of their parents and grandparents so that they will have a better appreciation of their heritage. Other families teach their children primarily about the dominant, mainstream culture in hopes that this will help their children get ahead in life.Some upper-class parents focus on teaching their children about the importance of wealth, power, and privilege; however, many downplay this aspect and want their children to make their own way in life, fearing that “spoiling them” will not be in their best interest. Middle-class parents have typically focused on academic achievement and the importance of hard work to achieve the American Dream. However, with the global recession that hit the U.S. economy hard between December 2007 and June 2009, optimism that persons in the middle class had previously passed on to their children diminished as homes went into foreclosure, jobs were lost and not replaced, and people saw their standard of living slip. Even then, some research showed that middle-class families felt slightly more secure financially than families at working- and lower-income levels, where parents continually struggle to keep a roof overhead and food on the table. Parents in lower-income categories often felt that they had little time to help their children learn about important things that might help them succeed in school and life (Kendall, 2002, 2011). Problems such as these contribute to and reinforce social inequality, and this is one of many reasons why conflict theorists are concerned about the long-term effects of the socialization process.However, we should note that socialization is a bidirectional process in which children and young people socialize their agents of socialization, including parents, teachers, and others, as well as receiving socialization from these important agents (Figure 4.13).Reciprocal socializationis the process by which the feelings, thoughts, appearance, and behavior of individuals who are undergoing socialization also have a direct influence on those agents of socialization who are attempting to influence them. Examples of this process include parents whose preferences in music, hairstyles, and clothing are influenced by their children, and teachers whose choice of words (“cool,” “you know,” “LOL,” and other slang terms) is similar to that of their students.Figure4.13Students are sent to school to be educated. However, what else will they learn in school beyond the academic curriculum? Sociologists differ in their responses to this question.Jamie Grill/Getty Images4-4bThe SchoolLO4Describehow schools socialize children in both formal and informal ways.Asthe amount of specialized technical and scientific knowledge has expanded rapidly and as the amount of time that children are in educational settings has increased, schools continue to play an enormous role in the socialization of young people. For many people, the formal education process is an undertaking that lasts up to twenty years.As the number of one-parent families and families in which both parents work outside the home has increased dramatically, the number of children in day-care and preschool programs has also grown rapidly. Nearly 11 million children younger than age 5 whose mothers are working are in some type of child-care arrangement where they spend, on average, about 36 hours a week. Potentially, more than 15 million children under the age of 6 need child care (Child Care Aware of America, 2014).Generally, studies have found that quality day-care and preschool programs have a positive effect on the overall socialization of children. These programs provide children with the opportunity to have frequent interactions with teachers and to learn how to build their language and literacy skills. High-quality programs also have a positive effect on the academic performance of children, particularly those from low-income families. Today, however, the cost of child-care programs has become a major concern for many families. For example, a year of center-based care for a four-year-old ranges from slightly more than $4,500 in Tennessee to more than $12,300 in Massachusetts (Child Care Aware of America, 2014).In schools ranging from kindergarten through grade 12, students learn specific mandated knowledge and skills. However, schools also have a profound effect on children’s self-image, beliefs, and values (Figure 4.13). As children enter school for the first time, they are evaluated and systematically compared with one another by the teacher. A permanent, official record is kept of each child’s personal behavior and academic activities. From a functionalist perspective, schools are responsible for(1)socialization, or teaching students to be productive members of society;(2)transmission of culture;(3)social control and personal development; and(4)the selection, training, and placement of individuals on different rungs in the society (Ballantine and Hammack, 2012).In contrast, conflict theorists assert that students have different experiences in the school system depending on their social class, their racial–ethnic background, the neighborhood in which they live, their gender, and other factors. For example, Langhout and Mitchell (2008), after investigating the “hidden curriculum” in a low-income elementary school, concluded that African American and Latino boys were disproportionately punished for violating the rules (e.g., raising your hand to speak) when compared to their white and female counterparts. Thus, schools do not socialize children for their own well-being but rather for their roles in school and the workforce, where it is important to be well-behaved and “know your place.” Students who are destined for leadership or elite positions acquire different skills and knowledge than those who will enter working-class and middle-class occupations.4-4cPeer GroupsLO5Explainthe role that peer groups and media play in socialization now, and predict the role that these agents will play in the future.As soon as we are old enough to have acquaintances outside the home, most of us begin to rely heavily on peer groups as a source of information and approval about social behavior. Apeer groupis a group of people who are linked by common interests, equal social position, and (usually) similar age. In early childhood, peer groups are often composed of classmates in day care, preschool, and elementary school. Preadolescence—the latter part of the elementary school years—is an age period in which children’s peer culture has an important effect on how children perceive themselves and how they internalize society’s expectations (Robnett and Susskind, 2010). For example, boys who havea large proportion of same-gender friends are more likely to reject “feminine” traits, which they associate with girls. As a result, this may play a part in socializing them to have negative attitudes toward femininity that they display later in life (Robnett and Susskind, 2010). In adolescence, peer groups are typically made up of people with similar interests and social activities. As adults, we continue to participate in peer groups of people with whom we share common interests and comparable occupations, income, and/or social position.Peer groups function as agents of socialization by contributing to our sense of “belonging” and our feelings of self-worth (Figure 4.14). As early as the preschool years, peer groups provide children with an opportunity for successful adaptation to situations such as gaining access to ongoing play, protecting shared activities from intruders, and building solidarity and mutual trust during ongoing activities (Corsaro, 2011). Unlike families and schools, peer groups provide children and adolescents with some degree of freedom from parents and other authority figures. They also teach cultural norms such as what constitutes “acceptable” behavior in a specific situation. Peer groups simultaneously reflect the larger culture and serve as a conduit for passing on culture to young people. As a result, the peer group is both a product of culture and one of its major transmitters.Figure4.14The pleasure of participating in activities with friends is one of the many attractions of adolescent peer groups. What groups have contributed the most to your sense of belonging and self-worth?© Photomatz/Shutterstock.comDo you think there is such a thing as “peer pressure”? Most of us are acutely aware of such a social force. Individuals must earn their acceptance with their peers by conforming to a given group’s norms, attitudes, speech patterns, and dress codes. When we conform to our peer group’s expectations, we are rewarded; if we do not conform, we may be ridiculed or even expelled from the group. Conforming to the demands of peers frequently places children and adolescents at cross-purposes with their parents. For example, young people are frequently under pressure to obtain certain valued material possessions (such as toys, clothing, athletic shoes, or cell phones); they then pass the pressure on to their parents through emotional pleas to purchase the desired items.4-4dMass MediaAn agent of socialization that has a profound impact on both children and adults is themass media, composed of large-scale organizations that use print or electronic means (such as radio, television, film, and the Internet) to communicate with large numbers of people. Today, the termmediaalso includes the many forms of Web-based and social media such as Facebook, Twitter, and YouTube. For many years, the media have functioned as socializing agents in several ways:(1)they inform us about events;(2)they introduce us to a wide variety of people;(3)they provide an array of viewpoints on current issues;(4)they make us aware of products and services that, if we purchase them, will supposedly help us to be accepted by others; and(5)they entertain us by providing the opportunity to live vicariously (through other people’s experiences).Although most of us take for granted that the media play an important part in contemporary socialization, we frequently underestimate the enormous influence that this agent of socialization may have on our attitudes and behavior.As you are aware, the use of social media such as Facebook and Twitter has grown exponentially in recent years. Today, 95 percent of teens report that they use the Internet, and most indicate that they use it to interact with friends and watch video content online that they previously might have watched on television (Nielsen, 2013). Withinhouseholds where teens are present, smartphones and tablets are the fastest-growing devices. Social networking is a rapidly increasing layer on top of existing layers of other media use (Figure 4.15).Figure4.15Texting, social networking, and using smartphones now provide us with instant access to friends, information, and entertainment around the clock. How does this compare to the socialization process when your parents or grandparents were children?© ndoeljindoel/Shutterstock.comIn the past young people between the ages of 12 and 17 watched much more TV than today. Research showed that the monthly time spent, on average, watching video on TV was more than 98 hours (Nielsen, 2013). Smartphones, tablets, and other mobile media now make it possible for young people to have access to social media 24 hours per day, 7 days per week, with little time for other influences or activities in their life. Does this make a significant difference in childhood socialization? Future studies will no doubt continue to examine new media’s effects on children and how increased use relates to grades, family interaction patterns, social networks, and other important issues in reaching maturity.Parents, educators, social scientists, and public officials have widely debated the consequences of young people watching violence on television. In addition to concerns about violence in television programming, motion pictures, and electronic games, television shows have been criticized for projecting negative images of women and people of color. Although the mass media have changed some of the roles that they depict women as playing, some newer characters tend to reinforce existing stereotypes of women as sex objects even when they are in professional roles such as doctors or lawyers. What effect do you think this has on children and young people as they develop their own ideas about the “adult world”? Throughout this text, we will look at additional examples of how the media socialize us in ways that we may or may not realize.4-4eGender SocializationLO6Identifyways in which gender socialization and racial–ethnic socialization occur.Gender socializationis the aspect of socialization that contains specific messages and practices concerning the nature of being female or male in a specific group or society. Through the process of gender socialization we learn about what attitudes and behaviors are considered to be appropriate for girls and boys, men and women, in a particular society. Different sets of gender norms are appropriate for females and males in the United States and most other nations. When do you first remember learning about gender-specific norms for your own appearance and behavior?One of the primary agents of gender socialization is the family. In some families, this process begins even before the child’s birth. Parents who learn the sex of the fetus through ultrasound or amniocentesis often purchase color-coded and gender-typed clothes, toys, and nursery decorations in anticipation of their daughter’s or son’s arrival. After birth, parents may respond differently toward male and female infants; they often play more roughly with boys and talk more lovingly to girls. Throughout childhood and adolescence, boys and girls are typically assigned different household chores and given different privileges such as boys being given more latitude to play farther away from home than girls and being allowed to stay out later at night (Figure 4.16).Figure4.16Do you believe that what this child is learning here will have an influence on his actions in the future? What other childhood experiences might offset early gender socialization?© rodimov/Shutterstock.comIn regard to gender socialization practices among various racial–ethnic groups, some sociologists have found that children typically are not taught to think of gender strictly in “male–female” terms. Both daughters and sonsare socialized toward autonomy, independence, self-confidence, and nurturance of children. Sociologist Patricia Hill Collins (2000) has suggested that “othermothers” (women other than a child’s biological mother) play an important part in the gender socialization and motivation of African American children, especially girls. Othermothers often serve as gender-role models and encourage women to become activists on behalf of their children and community (Collins, 2000). In the past, by contrast, Korean American and Latino/a families typically engaged in more-traditional gender socialization, but evidence in the 2010s suggests that this pattern has continued to change as young women are spending more time away from older family members and are gaining greater freedom of expression at school and in the workplace.Like the family, schools, peer groups, and the media also contribute to our gender socialization. From kindergarten through college, teachers and peers reward gender-appropriate attitudes and behavior. Sports reinforce traditional gender roles through a rigid division of events into male and female categories. The media are also a powerful source of gender socialization; starting very early in childhood, children’s books, television programs, movies, and music provide subtle and not-so-subtle messages about how boys and girls should act (seeChapter 11, “Sex, Gender, and Sexuality”).4-4fRacial–Ethnic SocializationIn addition to gender-role socialization, we receive racial socialization throughout our lives.Racial socializationis the aspect of socialization that contains specific messages and practices concerning the nature of our racial or ethnic status as it relates to our identity, interpersonal relationships, and location in the social hierarchy. Racial socialization includes direct statements regarding race, modeling behavior (wherein a child imitates the behavior of a parent or other caregiver), and indirect activities such as exposure to an environment that conveys a specific message about a racial or ethnic group (“We are better than they are,” for example).The most important aspects of racial identity and attitudes toward other racial–ethnic groups are passed down in families from generation to generation. As the sociologist Martin Marger (1994: 97) notes, “Fear of, dislike for, and antipathy toward one group or another is learned in much the same way that people learn to eat with a knife or fork rather than with their bare hands or to respect others’ privacy in personal matters.” These beliefs can be transmitted in subtle and largely unconscious ways; they do not have to be taught directly or intentionally.How early do you think racial socialization begins? Scholars have found that ethnic values and attitudes begin to crystallize among children as young as age four (Van Ausdale and Feagin, 2001). By this age, the society’s ethnic hierarchy has become apparent to the child. Some minority parents feel that racial socialization is essential because it provides children with the skills and abilities that they will need to survive in the larger society.4-5Socialization Through the Life CourseLO7Discussthe stages in the life course, and demonstrate why the process of socialization is important in each stage.Why is socialization a lifelong process? Throughout our lives, we continue to learn. Each time we experience a change in status (such as becoming a college student or getting married), we learn a new set of rules, roles, and relationships. Even before we achieve a new status, we often participate inanticipatory socialization—the process by which knowledge and skills are learned for future roles. Many societies organize social activities according to age and gather data regarding the age composition of the people who live in that society. Some societies have distinctrites of passage, based on age or other factors that publicly dramatize and validate changes in a person’s status. In the United States and other industrialized societies, the most common categories of age are childhood, adolescence, and adulthood (often subdivided into young adulthood, middle adulthood, and older adulthood).4-5aChildhoodSome social scientists believe that a child’s sense of self is formed at an early age and that it is difficult to change this self-perception later in life. Symbolic interactionists emphasize that during infancy and early childhood, family support and guidance are crucial to a child’s developing self-concept. In some families, children are provided with emotional warmth, feelings of mutual trust, and a sense of security. These families come closer to our ideal cultural belief that childhood should be a time of carefree play, safety, and freedom from economic, political, and sexual responsibilities. However, other families reflect the discrepancy between cultural ideals and reality—children grow up in a setting characterized by fear, danger, and risks that are created by parental neglect, emotional maltreatment, or premature economic and sexual demands. Abused and neglected children often experiencephysical consequences, such as damage to their growing brains, which can lead to cognitive delays or emotional difficulties. Psychological problems can also occur that involve high-risk behavior such as smoking, alcohol or drug abuse, or similar activities. Other psychological problems manifest as low self-esteem, an inability to trust others, feelings of isolation and powerlessness, and denial of one’s feelings.4-5bAdolescenceDid you know that some societies have not had a period of time in the life of the individual known as “adolescence”? In contemporary societies, the adolescent (or teenage) years represent a buffer between childhood and adulthood. It is a time during which young people pursue their own routes to self-identity and adulthood. Anticipatory socialization is often associated with adolescence, with many young people spending time planning or being educated for future roles they hope to occupy. Although no specific rites of passage exist in the United States to markeverychild’s transition between childhood and adolescence or between adolescence and adulthood, some rites of passage are observed. For example, a celebration known as a Bar Mitzvah is held for some Jewish boys on their thirteenth birthday, and a Bat Mitzvah is held for some Jewish girls on their twelfth birthday; these events mark the occasion upon which young people accept moral responsibility for their own actions and the fact that they are now old enough to own personal property. Similarly, some Latinas are honored with thequinceañera—a celebration of their fifteenth birthday that marks their passage into young womanhood (Figure 4.17). Although it is not officially designated as a rite of passage, many of us think of the time when we get our first driver’s license or graduate from high school as another way in which we mark the transition from one period of our life to the next.Figure4.17An important rite of passage for many Latinas is thequinceañera—a celebration of their fifteenth birthday and their passage into womanhood. Can you see how this occasion might also be a form of anticipatory socialization?Charles O. Cecil/AlamyAdolescence is often characterized by emotional and social unrest. In the process of developing their own identities, some young people come into conflict with parents, teachers, and other authority figures who attempt to restrict their freedom. Adolescents may also find themselves caught between the demands of adulthood and their own lack of financial independence and experience in the job market.The experiences of individuals during adolescence vary according to race, class, and gender. Based on their family’s economic situation and personal choices, someyoung people leave high school and move directly into the world of work, whereas others pursue a college education and may continue to receive advice and financial support from their parents. Others are involved in both the world of work and the world of higher education as they seek to support themselves and to acquire more years of formal education or vocational/career training. Whether or not a student works while in college may affect the process of adjusting to college life (seeFigure 4.18). In the second decade of the twenty-first century, more college students are exploring international study programs as part of their adult socialization to help them gain new insights into divergent cultures and the larger world of which they are a part (see “Sociology in Global Perspective”).Figure4.18Time Line for First-Semester College SocializationDavid R. Frazier Photolibrary, Inc/AlamyAdapting to new people and new situationsAnticipation and excitement about studying in a new settingInsecurity about academic demandsHomesicknessIf employed, trying to balance school and work lifeIan West/Bubbles Photolibrary/AlamySocial pressures from others: What would my parents think?Anticipation (and dread) of midterm exams and major papersTime-management problems between school and social lifeIntense need for a breakConcerns about role conflict between school and workImage Source/Getty ImagesPositive or negative assessment of grades so farPre-final studying and jittersMaking up for lost time and procrastinationFirst college illnesses likely to occur because of late hours, poor eating habits, and proximity to others who become illPotential problems with roommates or others who make excessive demands on one’s time and/or personal spaceThe Copyright Group/SuperStockFinal exams: late nights, extra effort, and stressConcerns about leaving new friends and college setting for winter breakAnticipation (and tension) associated with going home for break for those who have been awayReassessment of college choice, major, and career options: Am I on the right track?Acknowledgment that growth has occurred and much has been learned, both academically and otherwise, during the first college termSource: Based on the author’s observations of student life and on Kansas State University, 2010.Sociology in Global PerspectiveOpen Doors: Study Abroad and Global Socialization[T]hefirst month or so of the study abroad experience feels like a vacation in that everything is exciting and new. After this “honeymoon” period, the experience becomes something other than merely a vacation or fleeting visit. You start to relate to the people, the culture, and life in that country not from the eyes of a tourist passing through, but progressively from the eyes of those around you—the citizens who were born and raised there. That is the perspective which is unattainable without actually living in another country, and a perspective which I have come to appreciate and understand more fully as I settle back into life here back at home.—John R. R. Howie(2010), then a Boston College economics and Mandarin Chinese major, explaining what studying abroad at Peking University, in Beijing, meant to him. Howie has since graduated and is now employed as a financial analyst.Studying abroad is an important part of the college socialization process for preparing to live and work in an interconnected world. Here are a few interesting facts about studying abroad (adapted from Institute of International Education, 2014):More than 313,000 U.S. students participated in study-abroad programs for credit in 2012–2013, and this number continues to increase each year.The United Kingdom, Italy, Spain, France, and China are the top destinations for study abroad; however, Germany, Ireland, Costa Rica, Australia, Japan, and Africa are also popular destinations.The top fields of study for U.S. study-abroad students are STEM, business, social sciences, foreign languages, and fine and applied arts.More than 60 percent of study-abroad students remain in their host country for a short-term stay (summer or eight weeks or less during the academic year). About 37 percent spend one semester or one or two quarters in the host country, while 3 percent remain for an academic or calendar year.Sociologists are interested in studying the profile of U.S. study-abroad students because the data provide interesting insights on differences in students’ participation by classification, gender, race, and class. Based on the latest figures available (2014/2015), most students participating in study-abroad programs are classified as juniors or seniors. Women make up nearly 70 percent of all study-abroad students, and men make up about 30 percent. White students make up the vast majority of study-abroad students (73 percent). Other groups include Hispanic or Latino(a), Asian or Pacific Islander and black or African American students who make up 27 percent (Institute of International Education, 2016).Socialization for life in the global community is necessary for all students because of the increasing significance of international understanding and the need to learn how to live and work in a diversified nation and world. Even more important may be the opportunity for each student to gain direction and meaning in his or her own life. Do you think that studying abroad might make an important contribution to your own socialization while in college? Why or why not?Reflect & AnalyzeWhat are the positive aspects of study-abroad programs in the college socialization process? What are the limitations of such programs? If you are unable to participate in a study-abroad program, what other methods and resources might you use to gain “global socialization,” which could be beneficial in helping you meet your goals for the future?4-5cAdulthoodOne of the major differences between child socialization and adult socialization is the degree of freedom of choice. If young adults are able to support themselves financially, they gain the ability to make more choices about their own lives. In early adulthood (usually until about age forty), people work toward their own goals of creating relationships with others, finding employment, and seeking personal fulfillment. Of course, young adults continue to be socialized by their parents, teachers, peers, and the media, but they also learn new attitudes and behaviors. For example, when we marry or have children, we learn new roles as partners or parents.Workplace (occupational) socializationis one of the most important types of early adult socialization. This type of socialization tends to be most intense immediately after a person makes the transition from school to the workplace; however, many people experience continuous workplace socialization as a result of having more than one career in their lifetime.In middle adulthood—between the ages of forty and sixty-five—people begin to compare their accomplishmentswith their earlier expectations. This is the point at which people either decide that they have reached their goals or recognize that they have attained as much as they are likely to achieve.Some analysts divide late adulthood into three categories:(1)the “young-old” (ages sixty-five to seventy-four),(2)the “old-old” (ages seventy-five to eighty-five), and(3)the “oldest-old” (over age eighty-five).Others believe that these distinctions are arbitrary and that actual appearance and behavior are quite different based on people’s health status, socioeconomic level, and numerous other factors. Although these are somewhat arbitrary divisions, the “young-old” are less likely to suffer from disabling illnesses, whereas some of the “old-old” are more likely to suffer such illnesses. Increasingly, studies in gerontology and the sociology of medicine have come to question these arbitrary categories and show that many persons defy the expectations of their age grouping based on their individual genetic makeup, lifestyle choices, and zest for living. Perhaps “old age” is what we make it!4-5dLate Adulthood and AgeismIn older adulthood, some people are quite happy and content; others are not. Erik Erikson noted that difficult changes in adult attitudes and behavior occur in the last years of life, when people experience decreased physical ability, lower prestige, and the prospect of death. Older adults in industrialized societies may experiencesocial devaluation—wherein a person or group is considered to have less social value than other persons or groups. Social devaluation is especially acute when people are leaving roles that have defined their sense of social identity and provided them with meaningful activity (Figure 4.19).Figure4.19Throughout life, our self-concept is influenced by our interactions with others. How might the self-concept of these women be influenced by each other? By society at large?Sandy Huffaker/CorbisNegative images regarding older persons reinforceageism—prejudice and discrimination against people on the basis of age, particularly against older persons. Ageism is reinforced by stereotypes, whereby people have narrow, fixed images of certain groups. Older persons are often stereotyped as thinking and moving slowly; as being bound to themselves and their past, unable to change and grow; as being unable to move forward and often moving backward.Negative images also contribute to the view held by some that women are “old” ten or fifteen years sooner than men. In popular films, male characters increase inleadership roles and powerful positions as they grow older; women are either moved into the background or are given stereotypical roles that disparage gender and aging. Similarly, the multibillion-dollar cosmetics industry helps perpetuate the myth that age reduces the “sexual value” of women but increases it for men. Men’s sexual value is defined more in terms of personality, intelligence, and earning power than by physical appearance. For women, however, sexual attractiveness is based on youthful appearance. By idealizing this “youthful” image of women and playing up the fear of growing older, sponsors sell millions of products and services that claim to prevent or fix the “ravages” of aging.Although not all people act on appearances alone, Patricia Moore, an industrial designer, found that many do. At age twenty-seven, Moore disguised herself as an eighty-five-year-old woman by donning age-appropriate clothing and placing baby oil in her eyes to create the appearance of cataracts. With the help of a makeup artist, Moore supplemented the “aging process” with latex wrinkles, stained teeth, and a gray wig. For three years, “Old Pat Moore” went to various locations, including a grocery store, to see how people responded to her:When I did my grocery shopping while in character, I learned quickly that the Old Pat Moore behaved—and was treated—differently from the Young Pat Moore. When I was 85, people were more likely to jockey ahead of me in the checkout line. And even more interesting, I found that when it happened, I didn’t say anything to the offender, as I certainly would at age 27. It seemed somehow, even to me, that it was okay for them to do this to the Old Pat Moore, since they were undoubtedly busier than I was anyway. And further, they apparently thought it was okay, too! After all, little old ladies have plenty of time, don’t they? And then when I did get to the checkout counter, the clerk might start yelling, assuming I was deaf, or becoming immediately testy, assuming I would take a long time to get my money out, or would ask to have the price repeated, or somehow become confused about the transaction. What it all added up to was that people feared I would be trouble, so they tried to have as little to do with me as possible. And the amazing thing is that I began almost to believe it myself…. I think perhaps the worst thing about aging may be the overwhelming sense that everything around you is letting you know that you are not terribly important any more. (Moore with Conn, 1985: 75–76)Do you think we would find the same thing if we recreated Moore’s study today? We might find out what many older persons already know—it is other people’sreactionsto their age, not their age itself, that place them at a disadvantage. Consider, for example, that researchers in one study searched on Facebook for groups that concentrate on older people and found 84 groups (with about 25,500 members) created by people between the ages of 20 and 29 years that were extremely derogatory, encouraged such things as banning older people from public activities such as shopping, infantilized them, or used negative terminology to describe them. Although Facebook policies on hate speech prohibit singling out people based on their sex, sexual orientation, gender, illness status, disability, race, ethnicity, national origin, or religion, no such policy exists in regard to age and the problem of ageism (Adler, 2013).Many older people buffer themselves against ageism by continuing to view themselves as being in middle adulthood long after their actual chronological age would suggest otherwise. Other people begin a process of resocialization to redefine their own identity as mature adults.4-6ResocializationLO8Distinguishbetween voluntary and involuntary resocialization, and give examples of each.Resocializationis the process of learning a new and different set of attitudes, values, and behaviors from those in one’s background and previous experience. Resocialization may be voluntary or involuntary. In either case, people undergo changes that are much more rapid and pervasive than the gradual adaptations that socialization usually involves.4-6aVoluntary ResocializationResocialization is voluntary when we assume a new status (such as becoming a student, an employee, or a retiree) of our own free will. Sometimes, voluntary resocialization involves medical or psychological treatment or religious conversion, in which case the person’s existing attitudes, beliefs, and behaviors must undergo strenuous modification to a new regime and a new way of life. For example, resocialization for adult survivors of emotional/physical child abuse includes extensive therapy in order to form new patterns of thinking and action, somewhat like Alcoholics Anonymous and its twelve-step program, which has become the basis for many other programs dealing with addictive behavior.4-6bInvoluntary ResocializationInvoluntary resocialization occurs against a person’s wishes and generally takes place within atotal institution—a place where people are isolated from the rest of society for a set period of time and come under the control of the officials who run the institution (Goffman, 1961a). Military boot camps, jails and prisons, concentration camps, and some mental hospitals are considered total institutions. Involuntary resocialization is a two-step process. First, people are stripped of their former selves—ordepersonalized—through a degradation ceremony (Goffman, 1961a). For example, inmates entering prison are required to strip, shower, and wear assigned institutional clothing. In the process, they are searched, weighed, fingerprinted, photographed, and given no privacy even in showers and restrooms. Their official identification becomes not a name but a number. In this abrupt break from their former existence, they must leave behind their personal possessions and their family and friends. The depersonalization process continues as they are required to obey rigid rules and to conform to their new environment (Figure 4.20).Figure4.20New inmates are taught how to order their meals. Two fingers raised means two portions. There is no talking in line. Inmates must eat all their food. This “ceremony” suggests how much freedom and dignity an inmate loses when beginning the resocialization process.Journal Courier/The Image WorksThe second step in the resocialization process occurs when the staff members at an institution attempt to build a more compliant person. A system of rewards and punishments (such as providing or withholding television or exercise privileges) encourages conformity to institutional norms.Individuals respond to involuntary resocialization in different ways. Some people are rehabilitated; others become angry and hostile toward the system that has taken away their freedom. Although the assumed purpose of involuntary resocialization is to reform people so that they will conform to societal standards of conduct after their release, the ability of total institutions to modify offenders’ behavior in a meaningful manner has been widely questioned. In many prisons, for example, inmates may conform to the norms of the prison or of other inmates but have little respect for the norms and the laws of the larger society.4-7Looking Ahead: Socialization, Social Change, and Your FutureWhat do you think socialization will be like in the future? The family is likely to remain the institution that most fundamentally shapes and nurtures people’s personal values and self-identity. However, other institutions, including education, religion, and the media, will continue to exert a profound influence on individuals of all ages. A central value-oriented issue facing parents and teachers as they attempt to socialize children is the dominance of television, the Internet, and social media, which make it possible for children and young people to experience many thingsoutside their homes and schools and to communicate routinely with people around the world.The socialization process in colleges and universities will become more diverse as students have an even wider array of options in higher education, including attending traditional classes in brick-and-mortar buildings, taking independent-study courses, enrolling in online courses and degree programs, participating in study-abroad programs, and facing options that are unknown at this time. However, it remains to be seen whether newer approaches to socialization in higher education will be more effective and less stressful than current methods.A very important area of social change in regard to socialization has occurred with the distinction between “digital natives” and “digital immigrants” because people in each category supposedly see the world fundamentally differently. Also known as the Net Generation, Millennials, and Generation Y, individuals in the category ofdigital natives—which would include many of you reading this sentence—literally were born into the digital world, grew up with the Internet, and think absolutely nothing of the rapid changes that so quickly brought digital technology into all aspects of our lives. According to Marc Prensky (2001), who coined the termsdigital nativesanddigital immigrants,Today’s students—K through college—represent the first generations to grow up with this new technology. They have spent their entire lives surrounded by and using computers, videogames, digital music players, video cams, cell phones, and all the other toys and tools of the digital age. Today’s average college grads have spent less than 5,000 hours of their lives reading, but over 10,000 hours playing video games (not to mention 20,000 hours watching TV). Computer games, email, the Internet, cell phones and instant messaging are integral parts of their lives. It is now clear that as a result of this ubiquitous environment and sheer volume of their interaction with it, today’s studentsthink and process information fundamentally differentlyfrom their predecessors.By contrast, their predecessors, the “digital immigrants,” are persons who have extensively used older technologies and were socialized differently from their children. Digital immigrants have to be resocialized to think and live in a world of digital immersion. For example, you might communicate by shooting a YouTube video while your parents would write a letter or an essay (Economist, 2010).If there is validity to the distinction between digital natives and digital immigrants, then socialization will continue to change dramatically. Parents and teachers will seek to communicate in the language and style of their children and students. However, digital natives will need to be aware of, and tolerant toward, some of the more traditional ways of thinking and learning that may have unique merit for unraveling certain problems, learning specific forms of information, and completing specific projects.Socialization in the future is linked to new technologies that are being developed now. Some people in the United States, and many people throughout the world, do not have access to the digital technology that many of us take for granted. These are important social, economic, and political issues for now and the future. One thing remains clear: The socialization process will continue to be a dynamic and important part of our life whether we are learning information from parents and teachers, from a smartphone, or from a robot. What kind of future would you like to see?

SC_WD19_3a_NikitaThapaliya_1

Dr. Tracy LamontJefferson Healthcare1245 Prince StreetPhiladelphia, PA 10190Dear Dr. Lamont:Thank you for your interest in the upcoming Innovations in Biotechnology Conference running from May 10 to May 12 this year in Dallas, Texas. I have enclosed an information sheet that provides details about the conference and the program topics.As you may know, the Innovations in Biotechnology Conference is the largest gathering of biotechnology experts from around the world. Some of this year’s featured topics include the following:Nano biotechnologyBiosensors and biomarkersAnalytics and diagnosticsRegenerative medicineI hope that one or more of those topics interests you and your colleagues. I look forward to meeting you if you attend the conference.Sincerely,Keisha BallantyneDirector of Special Eventsenc.Seventh Annual Conference onInnovations in BiotechnologyHosted by Advantia BiotechMay 10-12, 2021 [insert bullet] Dallas, TXConference HighlightsThe Innovations in Biotechnology Conference brings together hundreds of experts and leaders from biotechnology, pharmaceutics, and academia to share and discuss recent advances in biotechnology research and application.Why Attend?Biotechnology depends on interdisciplinary interactions to spur research and applications in human, animal, and agricultural health and sustainability. The conference is designed to present a comprehensive, cogent snapshot of the field today, highlighting advances in research and practices that can be applied to future biotechonlogical challenges.At the conference, you can meet and mingle with other professionals and academics committed to learning about biotechnology and contributing to advancements in the field. The annual Innovations in Biotechnology Conference is the largest gathering of biotechnology experts from around the world. Who Attends?Leaders in biotechnology and pharmaceutical companiesExperts in healthcareScientists and technologistsResearchers at academic, government, and financial institutionsMembers of the scientific pressConference ProgramsThe conference programs are organized into four tracks.Days 1 and 2  May 10 & 11 Topic Track Plant and agricultural biotechnology 1 Food and nutritional biotechnology 2 Nano biotechnology 3 Environmental biotechnology 4 Medical biotechnology 3 Cell biology and immunology 2 Biosensors and biomarkers 1 Day 3……………………………………………………………………………………………………………. May 12 Topic Track Marine biotechnology 1 Industrial and microbial biotechnology 2 Analytics and diagnostics 3 Agricultural biotechnology 1 Mechanics of biotechnology 2 Regenerative medicine 4 Applied biotechnology 2 Dallas City AttractionsIn the evenings, take advantage of performances, restaurants, and activities available in the city. Dallas has a free trolley that takes you from the Downtown neighborhood to Uptown and the Dallas Arts District. Dallas has 15 districts with dining, shopping, and nightlife in each one. The following table lists a few suggestions. See www.advantia.cengage.com for more.For More InformationVisit our website at www.advantia.cengage.com.

NursingsSocialPolicyStatement

Nursing’s Social Policy Statement: An Overview“Nursing is the pivotal health care profession, highly valued for its specialized knowledge, skill, and caring in improving the health status of the public and ensuring safe, effective, quality care.”–(ANA, 2003)This revision of Nursing’s Social Policy Statement is the culmination of an extensive review process that also included a long public comment period. It builds on previous editions, especially the original 1980 document. The work describes the essence of the profession by discussing nursing as a profession that is both valued within a society and uniquely accountable to that society. The definition of nursing follows and describes contemporary nursing practice. A more detailed discussion of practice is presented in the sections about the scope and standards of practice and professional performance. A brief commentary about regulation provides an overview of professional, legal, and self-regulation expectations. This foundational ANA publication remains a key resource for nurses both to conceptualize the framework of nursing practice and to provide direction to nursing educators, administrators, and researchers. This publication also can inform other health professionals, legislators and other regulators, those who work in funding bodies, and members of the general public.Social Context of Nursing“Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.”–(ANA, 2002)Nursing, like other professions, is an essential part of the society out of which it grew and within which it continues to evolve. Nursing is responsible to society in the sense that nursing’s professional interest must be perceived as serving the interests of society. The mutually beneficial relationship between society and the nursing profession has been expressed as follows:Professions acquire recognition and relevance primarily in terms of needs, conditions, and traditions of particular societies and their members. It is societies (and often vested interests within them) that determine, in accord with their different technological and economic levels of development and their socioeconomic, political, and cultural conditions and values, what professional skills and knowledge they most need and desire. By various financial means, institutions will then emerge to train [educate] interested individuals to supply those needs.Logically, then, the professions open to individuals of any particular society are the property not of the individual, but of the society. What P.4individuals acquire through training [education] is professional knowledge and skill, not a profession or even part ownership of one. (Page, 1975, p. 7)The Social Concerns in Health Care and NursingHealth care continues to be a major focus of attention in the United States and worldwide. Many other societal concerns garner extensive attention and subsequent action by the nursing profession and its nurse constituency. Nursing has an active and enduring leadership role in public and political determinations about the following six key areas of health care:Organization, delivery, and financing of quality health careQuality health care is a human right for all (ANA, 2008b). To improve the quality of care, healthcare professionals must address these complex issues: increasing costs of care; health disparities; and the lack of safe, accessible, and available healthcare services and resources.Provision for the public’s healthIncreasing responsibility for basic self-help measures by the individual, family, group, community, or population complements the use of health promotion, disease prevention, and environmental measures.Expansion of nursing and healthcare knowledge and appropriate application of technologyIncorporation of research and evidence into practice helps inform the selection, implementation, and evaluation processes associated with the generation and application of knowledge and technology to healthcare outcomes.Expansion of healthcare resources and health policyExpanded facilities and workforce capacity for personal care and community health services are needed to support and enhance the capacity for self-help and self-care of individuals, families, groups, communities, and populations.Definitive planning for health policy and regulationCollaborative planning is responsive to consumer needs and provides for best resource use in the provision of health care for all.P.5Duties under extreme conditionsHealth professionals will weigh their duty to provide care with obligations to their own health and that of their families during disasters, pandemics, and other extreme emergencies.Of increasing importance, healthcare regulatory bodies set institutional standards for mandated quality of care, and other healthcare entities provide guidelines and protocols to attain quality care and better outcomes. The goals to provide quality while addressing the costs and quantity of available healthcare services will continue to be social and political priorities for nursing action.The Authority for Nursing Practice for NursesThe authority for nursing, as for other professions, is based on social responsibility, which in turn derives from a complex social base and a social contract.There is a social contract between society and the profession. Under its terms, society grants the professions authority over functions vital to itself and permits them considerable autonomy in the conduct of their own affairs. In return, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality and performance is at the heart of this relationship. It is the authentic hallmark of the mature profession. (Donabedian, 1976)Nursing’s social contract reflects the profession’s long-standing core values and ethics, which provide grounding for health care in society. It is easy to overlook this social contract underlying the nursing profession when faced with certain facets of contemporary society, including depersonalization, apathy, disconnectedness, and growing globalization. But upon closer examination, we see that society validates the existence of the profession through licensure, public affirmation, and legal and legislative parameters. Nursing’s response is to provide care to all who are in need, regardless of their cultural, social, or economic standing.The nursing profession fulfills society’s need for qualified and appropriately prepared individuals who embrace, and act according to, a strong code of ethics, especially when entrusted with the health care of individuals, families, groups, communities, and populations. The public ranks nurses among the top-few most trusted professionals. In turn, the nursing profession’s trusted position in society imposes a responsibility to provide the very best health P.6care. The provision of such health care relies on well-educated and clinically astute nurses and a professional association, comprising these same nurses, that establishes a code of ethics, standards of care and practice, educational and practice requirements, and policies that govern the profession.The American Nurses Association (ANA) is the professional organization that performs an essential function in articulating, maintaining, and strengthening the social contract that exists between nursing and society, upon which the authority to practice nursing is based. That social contract is evident in ANA’s most enduring and influential work, which is derived from the collective expertise of its constituent member associations, individual members, and affiliate member organizations. Such work includes:Developing and maintaining nursing’s code of ethics;Developing and maintaining the scope and standards of nursing practice;Supporting the development of nursing theory and research to explain observations and guide nursing practice;Establishing the educational requirements of professional practice;Defining professional role competence; andDeveloping programs and resources to establish and articulate nursing’s accountability to society, including practice policy work and governmental advocacy.The Elements of Nursing’s Social ContractThe following statements undergird professional nursing’s social contract with society:Humans manifest an essential unity of mind, body, and spirit.Human experience is contextually and culturally defined.Health and illness are human experiences. The presence of illness does not preclude health, nor does optimal health preclude illness.The relationship between the nurse and patient occurs within the context of the values and beliefs of the patient and nurse.P.7Public policy and the healthcare delivery system influence the health and well-being of society and professional nursing.Individual responsibility and interprofessional involvement are essential.These values and assumptions apply whether the recipient of professional nursing care is an individual, family, group, community, or population.Professional Collaboration in Health CareThe nursing profession is particularly focused on establishing effective working relationships and collaborative efforts essential to accomplish its health-oriented mission. Multiple factors combine to intensify the importance of direct human interactions, communication, and professional collaboration: the complexity, size, and culture of the healthcare system and its transitional and dynamic state; increasing public involvement in health policy; and a national focus on health.Collaboration means true partnership, valuing expertise, power, and respect on all sides and recognizing and accepting separate and combined spheres of activity and responsibility. Collaboration includes mutual safeguarding of the legitimate interests of each party and a commonality of goals that is recognized by all parties. The parties base their relationship upon trust and the recognition that each one’s contribution is richer and more truly real because of the strength and uniqueness of the others.Successful collaboration requires that nursing and its members respond to diversity by recognizing, assessing, and adapting the nature of working relationships with individuals, populations, and other health professionals and health workers. These efforts also extend to relationships within nursing and between nursing and representatives of the public in all environments where nursing practice may occur.Definition of NursingDefinitions of nursing have evolved to reflect the essential features of professional nursing:Provision of a caring relationship that facilitates health and healingAttention to the range of human experiences and responses to health and illness within the physical and social environmentsIntegration of assessment data with knowledge gained from an appreciation of the patient or the groupApplication of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinkingAdvancement of professional nursing knowledge through scholarly inquiryInfluence on social and public policy to promote social justiceAssurance of safe, quality, and evidence-based practiceIn her Notes on Nursing: What It Is and What It Is Not, published in 1859, Florence Nightingale defined nursing as having “charge of the personal health of somebody…, and what nursing has to do … is to put the patient in the best condition for nature to act upon him.”P.10A century later, Virginia Henderson (1961) defined the purpose of nursing as “to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.”In the original Nursing: A Social Policy Statement (ANA, 1980), nursing was defined as “the diagnosis and treatment of human responses to actual or potential health problems.”In 2001, ANA’s Code of Ethics With Interpretive Statements stated that “nursing encompassed the prevention of illness, the alleviation of suffering, and the protection, promotion and restoration of health in the care of individuals, families, groups, and communities.”The definition for nursing remains unchanged from the 2003 edition of Nursing’s Social Policy Statement:Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.This definition encompasses four essential characteristics of nursing: human responses or phenomena, theory application, nursing actions or interventions, and outcomes.Human ResponsesThese are the responses of individuals to actual or potential health problems, and which are the phenomena of concern to nurses. Human responses include any observable need, concern, condition, event, or fact of interest to nurses that may be the target of evidence-based nursing practice.Theory ApplicationIn nursing, theory is a set of interrelated concepts, definitions, or propositions used to systematically describe, explain, predict, or control human responses or phenomena of interest to nurses. Understanding theories of nursing and other disciplines precedes, and serves as a basis for, theory application through evidence-based nursing actions.P.11Nursing ActionsThe aims of nursing actions (also nursing interventions) are to protect, promote, and optimize health; to prevent illness and injury; to alleviate suffering; and to advocate for individuals, families, communities, and populations. Nursing actions are theoretically derived, evidence-based, and require welldeveloped intellectual competencies.OutcomesThe purpose of nursing actions is to produce beneficial outcomes in relation to identified human responses. Evaluation of outcomes of nursing actions determines whether the actions have been effective. Findings from nursing research provide rigorous scientific evidence of beneficial outcomes of specific nursing actions.Figure 1 depicts the intertwined relationships of human responses, theory application, nursing actions, and outcomes.View FigureKnowledge Base for Nursing PracticeNursing is a profession and is both a science and an art. The knowledge base for professional nursing practice includes nursing science, philosophy, and ethics; biology and psychology; and the social, physical, economic, organizational, and technological sciences. To refine and expand nursing’s knowledge base, nurses use theories that fit with professional nursing’s values of health and health care and that are relevant to professional nursing practice. Nurses apply research findings and implement the best evidence into their practice based on applicability to the individual, family, group, community, population, or system of care. These efforts generate knowledge and advance nursing science.Nurses are concerned with human experiences and responses across the life span. Nurses partner with individuals, families, communities, and populations to address issues such as the following:Promotion of health and wellnessPromotion of safety and quality of careCare, self-care processes, and care coordinationPhysical, emotional, and spiritual comfort, discomfort, and painAdaptation to physiological and pathophysiological processesEmotions related to the experience of birth, growth and development, health, illness, disease, and deathP.14Meanings ascribed to health, illness, and other conceptsLinguistic and cultural sensitivityHealth literacyDecision making and the ability to make choicesRelationships, role performance, and change processes within relationshipsSocial policies and their effects on healthHealthcare systems and their relationships to access, cost, and quality of health careThe environment and the prevention of disease and injuryNurses use their theoretical and evidence-based knowledge of these human experiences and responses to collaborate with patients and others to assess, diagnose, plan, implement, evaluate care, and identify outcomes. Nursing interventions aim to produce beneficial effects, contribute to quality outcomes, and—above all—do no harm. Nurses use the process that is evidence-based practice as a foundation of quality patient care to evaluate the effectiveness of care in relationship to identified outcomes.Scope of Nursing PracticeProfessional nursing has a single scope of practice that encompasses the range of activities from those of the beginning registered nurse through those of the most advanced level of nursing practice. The scope of practice statement (ANA, 2010) describes the who, what, where, when, why, and how of nursing practice. Although a single scope of professional nursing practice exists, the depth and breadth to which individual nurses engage in the total scope of professional nursing practice are dependent on their educational preparation and self-development, their experience, their role, the setting, and the nature of the populations they serve.Further, all nurses are responsible for practicing in accordance with recognized standards of professional nursing practice and the recognized professional code of ethics. Note that the lower level and foundation of the pyramid in Figure 2 (see next page) includes the scope of professional practice, standards of practice, and the code of ethics.Each nurse remains accountable for the quality of care within his or her scope of nursing practice. The level of application of standards varies with the education, experience, and skills of the individual nurse, who must rely on self-determination and self-regulation as the final level of professional accountability.Professional nursing’s scope of practice is dynamic and continually evolving, characterized by a flexible boundary responsive to the changing needs of society and the expanding knowledge base of applicable theoretical and P.16scientific domains. This scope of practice thus overlaps those of other professions involved in health care, whose boundaries are also constantly evolving. Members of any profession collaborate in various ways, such as:View FigureFIGURE 2. MODEL OF PROFESSIONAL NURSING PRACTICESharing knowledge, techniques, and ideas about how to deliver and evaluate quality and outcomes in health careSharing some functions and a common focus on the same overall missionRecognizing the expertise of others within and outside the profession, referring patients to other providers when appropriateP.17Nursing practice necessitates using such critical-thinking processes as the nursing process to apply the best available evidence to caregiving and promoting human functions and responses. Such caregiving includes, but is not limited to, initiating and maintaining comfort measures, establishing an environment conducive to well-being, providing health counseling, and teaching. Nurses not only independently establish plans of care but also carry out interventions prescribed by other authorized healthcare providers. Therefore, advocacy, communication, collaboration, and coordination are notable characteristics of nursing practice. Nurses base their practice on understanding the human condition across the life span and the relationship of the individual, family, group, community, or population within their own setting and environment.Registered nurses and nurses with advanced graduate education and preparation provide and direct nursing care. All registered nurses are educated in the art and science of nursing, with the goal of helping individuals, families, groups, communities, and populations to promote, attain, maintain, and restore health or to experience dignified death. Nurses may also develop expertise in a particular specialty. The increasing complexity of care reinforces ANA’s consistent advocacy (since 1965) of the baccalaureate degree in nursing as the preferred educational requirement for entry into professional nursing practice.Specialization in Nursing PracticeSpecialization involves focusing on nursing practice in a specific area, identified from within the whole field of professional nursing. ANA and specialty nursing organizations delineate the components of professional nursing practice that are essential for any particular specialty. The following characteristics must be met for ANA recognition of a nursing specialty. A nursing specialty (ANA, 2008d):Defines itself as nursing;Adheres to the overall licensure requirements of the profession;Subscribes to the overall purposes and functions of nursing;Is clearly defined;Can identify a need and demand for itself;Has a well-derived knowledge base particular to the practice of the nursing specialty;P.18Is concerned with phenomena of the discipline of nursing;Defines competencies for the area of specialty nursing practice;Has existing mechanisms for supporting, reviewing, and disseminating research to support its knowledge base;Has defined educational criteria for specialty preparation or graduate degree;Has continuing education programs or continuing competence mechanisms for nurses in the specialty;Is organized and represented by a national or international specialty association or branch of a parent organization;Is practiced nationally or internationally; andIncludes a substantial number of registered nurses who devote most of their practice to the specialty.Registered nurses may seek certification in a variety of specialized areas of nursing practice as a demonstration of competence (ANA, 2008c).Advanced Nursing PracticeAdvanced nursing practice builds on the competencies of the registered nurse and is characterized by the integration and application of a broad range of theoretical and evidence-based knowledge that occurs as part of graduate nursing education.Advanced Practice Registered NursesAdvanced practice registered nurses (APRNs) hold master’s or doctoral degrees in nursing, are certified in their designated specialty practice areas, and are recognized and approved to practice in their roles by state boards of nursing or other regulatory oversight bodies, often through special professional licensing processes.APRNs are educationally prepared in one of the four APRN roles (certified nurse practitioners, certified registered nurse anesthetists, certified nurse-midwives, and clinical nurse specialists) and in at least one of six possible population foci: family/individual across the life span; adult/gerontology; neonatal; P.19pediatrics; women’s health/gender-related health; psychiatric/mental health). Education, certification, and licensure of these individuals should be congruent with role and population foci (APRN Consensus, 2008). APRN specialty practice may focus on specific populations beyond those identified or focus on healthcare needs (such as oncology, palliative care, substance abuse, nephrology) that meet criteria for specialization as identified in the APRN Consensus Model. (See Appendix A for the full text of the APRN Consensus Model.)Additional Specialized Advanced Nursing PositionsThe profession of nursing is also dependent on continued expansion of nursing knowledge, education of nurses, appropriate organization and administration of nursing services, and development and adoption of policies consistent with values and assumptions that underlie the scope of professional nursing practice. Registered nurses may practice in such advanced positions as nurse educator, nurse administrator, nurse researcher, nurse policy analyst, advanced public health nurse, and informatics nurse specialist. These advanced roles require specific additional knowledge and skills gained through graduate-level education, holding master’s or doctoral degrees.Further details on the scope of professional nursing practice and the specifics that describe the who, what, where, when, why, and how of nursing practice for all registered nurses appear in the current version of Nursing: Scope and Standards of Practice (ANA, 2010).Standards of Professional Nursing PracticeTo guide professional practice, nursing has established standards of professional nursing practice, which are further categorized into standards of practice and standards of professional performance.Definition and Function of StandardsStandards are authoritative statements by which the nursing profession describes the responsibilities for which its practitioners are accountable. Standards reflect the values and priorities of the profession and provide direction for professional nursing practice and a framework for the evaluation of this practice. They also define the nursing profession’s accountability to the public and the outcomes for which registered nurses are responsible (ANA, 2010).Development of StandardsA professional nursing organization has a responsibility to its members and to the public it serves to develop standards of practice and standards of professional performance that may pertain to general or specialty practice. The American Nurses Association, as the professional organization for all registered nurses, has assumed the responsibility for developing generic standards that apply to the practice of all professional nurses. However, standards belong to the profession and thus require broad input into their development and P.22revision. The scope and standards of practice developed by ANA describe a competent level of nursing practice and professional performance common to all registered nurses (ANA, 2010).Standards of Professional Nursing PracticeThe Standards of Professional Nursing Practice are comprised of the Standards of Practice and the Standards of Professional Performance.Standards of PracticeThe Standards of Practice describe a competent level of nursing care, as demonstrated by the critical thinking model known as the nursing process, which includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. These standards encompass significant actions taken by registered nurses and form the foundation of the nurse’s decision making.Standards of Professional PerformanceThe Standards of Professional Performance describe a competent level of behavior in the professional role, including activities related to quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, resource utilization, and leadership. Registered nurses are accountable for their professional actions to themselves, their patients, their peers, and ultimately to society.The nursing process is usually conceptualized and presented as the integration of singular, concurrent actions of assessment, diagnosis, identification of outcomes, planning, implementation, and, finally, evaluation. Most often the nursing process is introduced to nursing students as a linear process with a feedback loop from evaluation to assessment, as reflected in Figure 3.Figure 4 reflects how the nursing process in practice is not linear, but relies heavily on the bidirectional feedback loops from and to each component. The standards of practice are co-located near the steps of the nursing process to represent the directive nature of the standards as the professional nurse completes each component of the nursing process. Similarly, the standards of professional performance relate to how the professional nurse adheres to the standards of practice, completes the nursing process, and addresses other nursing practice issues and concerns.P.23View FigureFIGURE 3. THE NURSING PROCESSView FigureFIGURE 4. THE NURSING PROCESS AND THE STANDARDS OF PROFESSIONAL NURSING PRACTICEP.24Application of Scope and StandardsContent within the current edition of Nursing: Scope and Standards of Practice should serve as the basis for the following:Policies, procedures, and protocolsPosition descriptions and performance appraisalsCertification activitiesEducational programs and offeringsDevelopment and evaluation of nursing service delivery systems and organizational structures, including the application of technologiesSpecialty nursing scope and standards of practiceQuality improvement systemsDatabasesRegulatory systemsHealthcare reimbursement and financing methodologiesEstablishing the legal standard of careCode of Ethics for NursesThe current code of ethics for the profession, Code of Ethics for Nurses With Interpretive Statements (ANA, 2001) “functions as a general guide for the profession’s members and as a social contract with the public that it serves” (Fowler, 2008, p. xi). It is the profession’s expression of the values, duties, and commitments to that public. Its nine provisions give voice to professional nurses and delineate what the nurse owes not only to others but also to him- or herself. This includes, but is not limited to, personal and professional growth, preserving integrity, and safety (Fowler, 2008).Although the Code of Ethics for Nurses is intended to be a living document for nurses, and health care is becoming more complex, the basic tenets found within this particular code of ethics remain unchanged. For example, Guide to the Code of Ethics for Nurses: Interpretation and Application (Fowler, 2008) provides interpretation and examples of the application of the nine ethical provisions.P.25Autonomy and Competent PracticeAutonomy is the capacity of a nurse to determine his or her own actions through independent choice within the full scope of nursing practice (Ballou, 1998). Competence is foundational to autonomy: the public has a right to expect nurses to demonstrate professional competence. The nursing profession and professional associations must shape and guide any practice, assuring nursing competence.The key indicators of competent practice are identified with each standard of practice and professional performance. For a standard to be met, all the listed competencies must be met. An individual who demonstrates competence is performing successfully at an expected level. A competency is an expected level of performance that integrates knowledge, skills, abilities, and judgment. Standards should remain stable over time because they reflect the philosophical values of the profession. Competency statements, however, may be revised more frequently to incorporate advances in scientific knowledge and expectations for nursing practice.Assurance of competence is the shared responsibility of the profession, individual nurses, professional organizations, credentialing and certification entities, regulatory agencies, employers, and other key stakeholders (ANA, 2008c).Regulation of Professional NursingFigure 5 (see next page) depicts the roles and relationships associated with the regulation of nursing practice. The model recognizes the contributions of professional and specialty nursing organizations, educational institutions, credentialing and accrediting organizations, and regulatory agencies; explains the role of workplace policies and procedures; and confirms the individual nurse’s ultimate responsibility and accountability for defining nursing practice (Styles, Schumann, Bickford, & White, 2008).The Scope of Nursing Practice, the Standards of Professional Nursing Practice, and the Code of Ethics for Nurses serve as the foundation for legislation and regulatory policies to assure protection of the public’s safety (Styles, Schumann, Bickford, & White, 2008).Under the terms of a social contract between society and the profession, society grants authority over functions vital to the profession and permits considerable autonomy in the conduct of its own affairs. Professional nursing, like other professions, is accountable for ensuring that its members act in the public interest while providing the unique service that society has entrusted to them. The processes by which the profession does this include professional regulation, legal regulation, and self-regulation. The Scope of Nursing Practice, the Standards of Professional Nursing Practice, the Code of Ethics for Nurses, and the current social policy statement are components of professional regulation and serve as the foundation for legislation, regulatory policy making, and nursing practice that may be set in place to help assure protection of the public’s safety.P.28View FigureFIGURE 5. MODEL OF PROFESSIONAL NURSING PRACTICE REGULATIONProfessional RegulationProfessional regulation is a profession’s oversight, monitoring, and control of its members based on principles, guidelines, and rules deemed important. Professional regulation of nursing practice begins with the professional definition of nursing and the delineation of the scope of professional nursing practice. Professional standards are derived from the scope of nursing practice.The social contract for nursing has been made specific through the professional society’s work, derived from the collective expertise of the American Nurses Association, in collaboration with members of its constituent member associations and members of other nursing organizations. These responsibilities include the following:P.29Establishing and maintaining a professional code of ethicsDetermining standards of practiceFostering the development of nursing theory, derived from nursing researchEstablishing nursing practice built on a base of best evidenceEstablishing the specifications for the educational requirements for entry into professional practice at basic and advanced levelsDeveloping certification processes as measures of professional competenceCertification is a judgment of competence made by nurses who are themselves practicing within the area of specialization. Certification is the formal recognition of the knowledge, skills, abilities, judgment, and experience demonstrated by the achievement of formal criteria identified by the profession. Credentialing boards develop and implement certification examinations and procedures for nurses who wish to have their specialty-practice knowledge recognized by the profession and the public. One component of the required evidence is successful completion of an examination that tests the knowledge base for the selected area of practice. Other requirements relate to the requisite content of course work and the amount of practice hours. Credentialing bodies may elect to use professional portfolios as psychometrically and legally defensible alternatives for certification examinations. Professional portfolios provide a comprehensive and reflective representation of professional abilities, achievements, and efforts.Contemporary specialty nursing practice is in transition in response to the increasing complexity of care and exponential explosion of data, information, and knowledge. Specialization is a mark of the advancement of the nursing profession and assists in clarifying, revising, and strengthening existing practice. Specialization not only expedites the production of new knowledge and its application in practice, but also provides preparation for teaching and research related to any defined area of nursing. The specialist in nursing practice is evolving to be a nurse who has become expert in a defined area of knowledge and nursing practice through study and supervised practice at the graduate (master’s or doctoral) level.P.30Legal RegulationLegal regulation is the oversight, monitoring, and control of designated professionals, based on applicable statutes and regulations, accompanied by the interpretation of these laws. All nurses are legally accountable for actions taken in the course of professional nursing practice, as well as for actions delegated by the nurse to others assisting in provision of nursing care. Such accountability is accomplished through legal regulatory mechanisms of licensure; granting of authority to practice, such as nurse practice acts; and criminal and civil laws.The legal contract between society and the professions is defined by statute and by associated rules and regulations. State nurse practice acts and related legislation and regulations serve as the explicit codification of the profession’s obligation to act in the best interests of society. Nurse practice acts grant nurses the authority to practice and grant society the authority to sanction nurses who violate the norms of the profession or act in a manner that threatens the safety of the public.Statutory definitions of nursing should be compatible with, and build upon, the profession’s definition of its practice base. They must be general enough to provide for the dynamic nature of an evolving scope of nursing practice. Society is best served when consistent definitions of the scope of nursing and of advanced practice nursing are used by each state’s board of nursing and other regulatory bodies. This allows residents of all states to access the full range of nursing services. Multiple stakeholders have established a collaborative effort to garner consensus in this arena.Institutional Policies and ProceduresNursing practice occurs within societal institutions, organizations, and settings that have accompanying policies, procedures, rules, and regulations. The scope and standards of practice for nursing and nursing specialties should help guide development of institutional policies and procedures to create a more detailed representation of what constitutes safe, quality, and evidence-based nursing practice.Self-RegulationSelf-regulation, which requires personal accountability for the knowledge base for professional practice, is an individual’s demonstrated personal control based on principles, guidelines, and rules deemed important. Nurses develop P.31and maintain current knowledge, skills, and abilities through formal academic programs and continuing education professional development programs. When available, nurses pursue certification in their area of practice to demonstrate this competence.View FigureFIGURE 6. SELF-DETERMINATION IN THE MODEL OF PROFESSIONAL NURSING PRACTICE REGULATIONNurses exercise autonomy and freedom within their scope of practice. Autonomy is defined as the capacity of a nurse to determine his or her own actions through independent choice within the full scope of nursing practice (Ballou, 1998). Autonomy and freedom are based on the nurse’s commitment to self-regulation and accountability for practice. In Figure 6, the apex of the pyramid, labeled Self-Determination, represents autonomy, self-regulation, and accountability for practice.P.32Competence is foundational to autonomy. Nursing competency is an expected level of performance that integrates knowledge, skills, abilities, and judgment (ANA, 2008d). Greater autonomy and freedom in nursing practice are based on broader authority rooted in expert or advanced knowledge in selected areas of nursing. This expert knowledge is associated with greater self-discipline and responsibility for direct care practice and for advancement of the nursing profession. A greater degree of autonomy not only imposes a greater duty to act and to do so competently but also increases accountability.Nurses also regulate their own practice by participating in peer review. Continuous performance improvement fosters the refinement of knowledge, skills, and clinical decision-making processes at all levels and in all areas of professional nursing practice. As expressed in the profession’s code of ethics, peer review is one mechanism by which nurses are held accountable for practice. As noted in Provision 3.4 (Standards and Review Mechanism) in Code of Ethics for Nurses with Interpretive Statements, nurses should also be active participants in the development of policies and review mechanisms designed to promote patient safety, reduce the likelihood of errors, and address both environmental system factors and human factors that present increased risk to patients. In addition, when errors do occur, nurses are expected to follow established guidelines in reporting committed or observed errors. The focus should be directed to improving systems, rather than projecting blame.Application of Nursing’s Social Policy StatementRegistered nurses should find the content within Nursing’s Social Policy Statement: The Essence of the Profession pertinent to everyday practice. The description of nursing as a profession valued within society, definition of nursing, presentation of the nursing process, and discussion of regulation set the stage for practice by promoting understanding.Nursing faculty should find content within this edition of Nursing’s Social Policy Statement that is critical for inclusion in curricula and course materials in undergraduate-, graduate-, and doctoral-level education. Similarly, nurses in professional development roles reinforce the concepts presented in this resource in the practice setting, especially those related to autonomy, competence, scope and standards of nursing practice, and the nursing process.Students will benefit from reading this statement on nursing’s social policy as they learn about the evolution of their profession through its key attributes: the definition of nursing, the profession’s delineation of the characteristics of a nursing specialty, and the delineation of its scope of practice and accompanying standards and competency statements. The models depicting the nursing process, with its feedback loops and the relationship of the standards of practice and professional performance to the nursing process, will be invaluable in generating improved understanding of the complexity of nursing practice.P.34Similarly, clear delineation of the six social concerns in health care, and other statements that undergird nursing’s social contract with society, reaffirm the importance of collaboration within nursing and interprofessional healthcare teams. Registered nurses will experience even greater relevance of this content in every practice setting.Nurse administrators should use this nursing social policy statement as a resource for strategic planning activities, public explanations about nursing and its registered nurses, and the development of vision and mission statements. Members of legal and regulatory bodies and organizations should review this document to understand better how professional, self-, and legal regulation can complement—rather than conflict with—each other. Healthcare consumers may wish to use the social policy statement to understand better the foundation upon which the nursing profession and its registered nurses base their practice.ConclusionThis social policy statement describes the pivotal nature and role of professional nursing in society and health care. The definition of nursing, introduction of the scope and accompanying standards of professional nursing practice, and discussion of specialization and regulation within the social context in which nurses practice provide an overview of the essence of nursing. Registered nurses focus their specialized knowledge, skills, and caring on improving the health status of the public and ensuring safe, effective, quality care. This statement serves as a resource to assist nurses in conceptualizing their professional practice and provides direction to educators, administrators, and researchers within nursing. This statement also informs other health professionals, legislators and other regulators, funding bodies, and the public about nursing’s social responsibility, accountability, and contribution to health care.ReferencesAll web-based references were retrieved May 31, 2010.American Nurses Association. (1980). Nursing: A social policy statement. Kansas City, MO: American Nurses Publishing.American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Nursesbooks.org.American Nurses Association. (2002). Nursing’s agenda for the future: A call to the nation. http://nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/Reports.aspxAmerican Nurses Association. (2003). Nursing’s social policy statement (2nd ed.). Silver Spring, MD: Nursesbooks.org.American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Nursesbooks.org.American Nurses Association. (2008a). Adapting standards of care under extreme conditions: Guidance for professionals during disasters, pandemics, and other extreme emergencies. Silver Spring, MD: Author.American Nurses Association. (2008b). ANA’s health system reform agenda. www.nursingworld.org/healthreformagendaP.38American Nurses Association. (2008c). Professional role competence position statement. http://nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/ANAPositionStatements/practice/PositionStatementProfessionalRoleCompetence.aspxAmerican Nurses Association. (2008d). Recognition of a nursing specialty, approval of a specialty nursing scope of practice statement, and acknowledgment of specialty nursing standards of practice. Silver Spring, MD: Author.APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification and education. http://www.nursingworld.org/ConsensusModelforAPRNBallou, K. A. (1998). Concept analysis of autonomy. Journal of Professional Nursing, 14(2), 102-110.Bibliographic LinksDonabedian, A. (1976). Forward, in M. Phaneuf, The nursing audit: Self-regulation in nursing practice (2nd ed., p. 8). New York: Appleton-Century-Crofts.Fowler, Marsha D. M. (Ed.). (2008). Guide to the code of ethics for nurses: Interpretation and application. Silver Spring, MD: Nursesbooks.org.Henderson, V. (1961). Basic principles of nursing care (p. 42). London: International Council of Nurses.Nightingale, F. (1859). Notes on nursing: What it is and what it is not (Preface, p. 75). London: Harrison and Sons. (Facsimile ed., J. B. Lippincott Company, 1946).Page, B. B. (1975). Who owns the profession? Hastings Center Report, 5 (5, October), 7-8. The Hastings Center: Garrison, NY.Styles, M. M., Schumann, M. J., Bickford, C. J., & White, K. M. (2008). Specialization and credentialing in nursing revisited: Understanding the issues, advancing the profession. Silver Spring, MD: Nursesbooks.org.GlossaryAdvanced practice registered nurse (APRN)A certified nurse practitioner, certified registered nurse anesthetist, certified nurse midwife, or clinical nurse specialist who is educationally prepared (usually at a post-bacca-laureate level), accredited by a national accrediting body, and has current certification by a national certifying body in the appropriate APRN role and at least one population focus. See also Population focus; each type of APRN.AutonomyThe capacity of a nurse to determine his/her own actions through independent choice, including demonstration of competence, within the full scope of nursing practice.Certified nurse practitioner (CNP)A registered nurse who is professionally prepared to provide direct primary care and acute care (initial, ongoing, and comprehensive) along the wellness-illness continuum and in all settings. Clinical CNP care includes health promotion, disease prevention, health education, and counseling as well as the diagnosis and management of acute and chronic diseases (APRN Consensus, 2008).Certified registered nurse anesthetist (CRNA)A registered nurse who is prepared to provide full-spectrum anesthesia care and anesthesia-related care for individuals across the lifespan, whose health status may range from healthy through all recognized levels of acuity, including persons with immediate, severe, or life-threatening illnesses or injury (APRN Consensus, 2008).P.40Certified nurse midwife (CNM)A registered nurse who is prepared to provide primary health care services to women throughout the lifespan, including gynecologic care, family planning services, preconception care, prenatal and postpartum care, childbirth, care of the newborn, and treating the male partner of the female client for sexually transmitted disease and reproductive health (APRN Consensus, 2008).Clinical nurse specialist (CNS)A registered nurse who is professionally prepared to integrate care across the continuum and through the patient, nurse, and system spheres of influence. The primary CNS goal is continuous improvement of patient outcomes and nursing care. The CNS is responsible and accountable for diagnosis and treatment of health/illness states, disease management, health promotion, and prevention of illness and risk behaviors (APRN Consensus, 2008).Code of ethics (nursing)A set of provisions that makes explicit the primary goals, values, and obligations of the nursing profession and expresses its values, duties, and commitments to the society of which it is a part. In the United States, nurses abide by and adhere to the Code of Ethics for Nurses (ANA, 2001).CollaborationA professional healthcare partnership grounded in a reciprocal and respectful recognition and acceptance of each partner’s unique expertise, power, and sphere of influence and responsibilities; the commonality of goals; the mutual safeguarding of the legitimate interest of each party; and the advantages of such a relationship.CompetencyAn expected and measurable level of nursing performance that integrates knowledge, skills, abilities, and judgment that is based on established scientific knowledge and expectations for nursing practice.Evidence-based practiceA scholarly and systematic problem-solving paradigm that results in the delivery of high quality health care.Human responsesThe phenomena of concern to nurses that include any observable need, concern, condition, event, or fact of interest actual or potential health problems.P.41NursingThe protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.Nursing actionsTheoretically derived and evidence-based interventions that are intended to protect, promote, and optimize health; prevent illness and injury; alleviate suffering; advocate for individuals, families, communities, and populations; and otherwise produce beneficial outcomes.Nursing practiceThe collective professional activities of nurses that are characterized by the interrelations of human responses, theory application, nursing actions, and outcomes.Nursing processA critical thinking model comprising the integration of singular, concurrent actions of these six components: assessment, diagnosis, identification of outcomes, planning, implementation, and evaluation.Outcomes (nursing)The results of nursing actions, in relation to identified human responses, based on findings from nursing research, the efficacy and benefit of which are determined by evaluation.Population focusAny one of these six APRN practice areas: family/individual across the life span; adult/gerontology; neonatal; pediatrics; women’s health/gender-related health; psychiatric/mental health.Registered nurse (RN)An individual registered or licensed by a state, commonwealth, territory, government, or other regulatory body to practice as a registered nurse.Regulation of nursing practiceThe processes of governance and controls established by authorized bodies as standards, guidelines, protocols, and other mandates for defining, attaining, and maintaining mandated quality of care and practice.P.42Scope of Nursing PracticeThe description of the who, what, where, when, why, and how of nursing practice that addresses the range of nursing practice activities common to all registered nurses. When considered in conjunction with the Standards of Professional Nursing Practice and the Code of Ethics for Nurses, the competent level of nursing common to all registered nurses is comprehensively described.Standards (nursing)Authoritative statements by which the nursing profession describes the responsibilities for which its practitioners are accountable, the outcomes for which registered nurses are responsible, and by which the quality of practice, service, or education can be evaluated.Standards of PracticeThe subset of nursing standards that describes a competent level of nursing care as demonstrated by the nursing process that forms the basis for the decision making of registered nurses and that encompasses all significant nursing actions. See also: Nursing process.Standards of Professional Nursing PracticeThe set of nursing standards comprised of the Standards of Practice and the Standards of Professional Performance, with each constituent standard having its own set of key indicators of competence. For a standard to be met, all the listed competencies must be met. When considered in conjunction with the Scope of Nursing Practice, comprehensively describes the competent level of nursing common to all registered nurses.Standards of Professional PerformanceThe subset of nursing standards that describes a competent level of activities and behavior in the professional role for the registered nurse by which they are accountable for their professional actions to themselves, their patients, their peers, and society.Theory (nursing)A set of interrelated concepts, definitions, or propositions used to systematically describe, explain, predict, or control human responses or phenomena of interest to nurses.Appendix A.Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education (2008)The content in this appendix is not current and is of historical significance only.P.44About the Consensus Model ReportAs underscored by the inclusion of APRNs in recent health system reform efforts, there is increased appreciation of the important role that APRNs can play in improving access to quality cost-effective care. However, a proliferation of nursing specializations, debates on appropriate credentials and scope of practice, and a lack of uniformity in state regulations have limited the ability of patients to access APRN care.The document that is reproduced in this appendix, and that was completed in July 2008 and endorsed by 44 organizations, delineates the model for future regulation of advanced practice registered nurses. This Consensus Model, when implemented, will standardize each aspect of the regulatory process for APRNs, resulting in increased mobility for APRNs and increased access to APRN care.The document was completed through the collaborative work of the APRN Consensus Workgroup and National Council of State Boards of Nursing APRN Advisory Committee, with extensive input from the larger APRN stakeholder community.(SOURCE: American Nurses Association, 2009: http://www.nursingworld.org/cmissuebrief)P.45Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & EducationJuly 7, 2008Completed through the work of the APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory CommitteeP.46The APRN Consensus Work Group and the APRN Joint Dialogue Group members would like to recognize the significant contribution to the development of this report made by Jean Johnson, PhD, RN-C, FAAN, Senior Associate Dean, Health Sciences, George Washington School of Medicine and Health Sciences. Consensus could not have been reached without her experienced and dedicated facilitation of these two national, multi-organizational groups.P.47LIST OF ENDORSING ORGANIZATIONSThis Final Report of the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee has been disseminated to participating organizations. The names of endorsing organizations will be added periodically.The following organizations have endorsed the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education:(Posted July 2009)N=46Academy of Medical-Surgical Nurses (AMSN)Accreditation Commission for Midwifery Education (ACME)American Academy of Nurse Practitioners (AANP)American Academy of Nurse Practitioners Certification ProgramAmerican Association of Colleges of Nursing (AACN)American Association of Critical-Care Nurses (AACN)American Association of Critical-Care Nurses Certification CorporationAmerican Association of Legal Nurse Consultants (AALNC)American Association of Nurse Anesthetists (AANA)American Board of Nursing Specialties (ABNS)American College of Nurse-Midwives (ACNM)American College of Nurse Practitioners (ACNP)American Holistic Nurses Association (AHNA)American Midwifery Certification Board (AMCB)American Nurses Association (ANA)American Nurses Credentialing Center (ANCC)American Psychiatric Nurses Association (APNA)Arkansas State Board of NursingAssociation of Faculties of Pediatric Nurse Practitioners (AFPNP)Commission on Collegiate Nursing Education (CCNE)Council on Accreditation of Nurse Anesthesia Educational Programs (COA)Dermatology Nurses Association (DNA)Dermatology Nursing Certification Board (DNCB)Emergency Nurses Association (ENA)Gerontological Advanced Practice Nurses Association (GAPNA)Hospice and Palliative Nurses Association (HPNA)The International Society of Psychiatric Nurses (ISPN)National Association of Clinical Nurse Specialists (NACNS)National Association of Orthopedic Nurses (NAON)National Association of Pediatric Nurse Practitioners (NAPNAP)National Board for Certification of Hospice and Palliative Nurses (NBCHPN)National Board on Certification & Recertification of Nurse Anesthetists (NBCRNA)National Certification Corporation (NCC)National Council of State Boards of Nursing (NCSBN)National Gerontological Nursing Association (NGNA)National League for Nursing (NLN)P.48National League for Nursing Accrediting Commission, Inc. (NLNAC)National Organization of Nurse Practitioner Faculties (NONPF)Nurse Practitioners in Women’s Health (NPWH)Nurses Organization of Veterans Affairs (NOVA)Oncology Nursing Certification Corporation (ONCC)Oncology Nursing Society (ONS)Orthopedic Nurses Certification Board (ONCB)Pediatric Nursing Certification Board (PNCB)Wound, Ostomy and Continence Nurses Society (WOCN)Wound, Ostomy and Continence Nursing Certification Board (WOCNCB)P.49INTRODUCTIONAdvanced Practice Registered Nurses (APRNs) have expanded in numbers and capabilities over the past several decades with APRNs being highly valued and an integral part of the health care system. Because of the importance of APRNs in caring for the current and future health needs of patients, the education, accreditation, certification and licensure of APRNs need to be effectively aligned in order to continue to ensure patient safety while expanding patient access to APRNs.APRNs include certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists and certified nurse practitioners. Each has a unique history and context, but shares the commonality of being APRNs. While education, accreditation, and certification are necessary components of an overall approach to preparing an APRN for practice, the licensing boards-governed by state regulations and statutes-are the final arbiters of who is recognized to practice within a given state. Currently, there is no uniform model of regulation of APRNs across the states. Each state independently determines the APRN legal scope of practice, the roles that are recognized, the criteria for entry-into advanced practice and the certification examinations accepted for entry-level competence assessment. This has created a significant barrier for APRNs to easily move from state to state and has decreased access to care for patients.Many nurses with advanced graduate nursing preparation practice in roles and specialties e.g., informatics, public health, education, or administration) that are essential to advance the health of the public but do not focus on direct care to individuals and, therefore, their practice does not require regulatory recognition beyond the Registered Nurse license granted by state boards of nursing. Like the four current APRN roles, practice in these other advanced specialty nursing roles requires specialized knowledge and skills acquired through graduate-level education. Although extremely important to the nursing profession and to the delivery of safe, high quality patient care, these other advanced, graduate nursing roles, which do not focus on direct patient care, are not roles for Advanced Practice Registered Nurses (APRN) and are not the subject or focus of the Regulatory Model presented in this paper.The model for APRN regulation is the product of substantial work conducted by the Advanced Practice Nursing Consensus Work Group and the National Council of State Boards of Nursing (NCSBN) APRN Committee. While these groups began work independent of each other, they came together through representatives of each group participating in what was labeled the APRN Joint Dialogue Group. The outcome of this work has been unanimous agreement on most of the recommendations included in this document. In a few instances, when agreement was not unanimous a 66% majority was used to determine the final recommendation. However, extensive dialogue and transparency in the decision-making process is reflected in each recommendation. The background of each group can be found on pages 13-16 and individual and organizational participants in each group in Appendices C-H.This document defines APRN practice, describes the APRN regulatory model, identifies the titles to be used, defines specialty, describes the emergence of new roles and population foci, and presents strategies for implementation.P.50Overview of APRN Model of RegulationThe APRN Model of Regulation described will be the model of the future. It is recognized that current regulation of APRNs does not reflect all of the components described in this paper and will evolve incrementally over time. A proposed timeline for implementation is presented at the end of the paper.In this APRN model of regulation there are four roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), and certified nurse practitioner (CNP). These four roles are given the title of advanced practice registered nurse (APRN). APRNs are educated in one of the four roles and in at least one of six population foci: family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women’s health/gender-related or psych/mental health. APRN education programs, including degree-granting and post-graduate education programs1, are accredited. APRN education consists of a broad-based education, including three separate graduate-level courses in advanced physiology/pathophysiology, health assessment and pharmacology as well as appropriate clinical experiences. All developing APRN education programs or tracks go through a pre-approval, pre-accreditation, or accreditation process prior to admitting students. APRN education programs must be housed within graduate programs that are nationally accredited2 and their graduates must be eligible for national certification used for state licensure.Individuals who have the appropriate education will sit for a certification examination to assess national competencies of the APRN core, role and at least one population focus area of practice for regulatory purposes. APRN certification programs will be accredited by a national certification accrediting body3. APRN certification programs will require a continued competency mechanism.Individuals will be licensed as independent practitioners for practice at the level of one of the four APRN roles within at least one of the six identified population foci. Education, certification, and licensure of an individual must be congruent in terms of role and population foci. APRNs may specialize but they cannot be licensed solely within a specialty area. In addition, specialties can provide depth in one’s practice within the established population foci. Education and assessment strategies for specialty areas will be developed by the nursing profession, i.e., nursing organizations and special interest groups. Education for a specialty can occur concurrently with APRN education required for licensure or through post-graduate education. Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by the professional organizations.P.51In addition, a mechanism that enhances the communication and transparency among APRN licensure, accreditation, certification and education bodies (LACE) will be developed and supported.APRN REGULATORY MODELAPRN Regulation includes the essential elements: licensure, accreditation, certification and education (LACE).Licensure is the granting of authority to practice.Accreditation is the formal review and approval by a recognized agency of educational degree or certification programs in nursing or nursing-related programs.Certification is the formal recognition of the knowledge, skills, and experience demonstrated by the achievement of standards identified by the profession.Education is the formal preparation of APRNs in graduate degree-granting or post-graduate certificate programs.The APRN Regulatory Model applies to all elements of LACE. Each of these elements plays an essential part in the implementation of the model.Definition of Advanced Practice Registered NurseCharacteristics of the advanced practice registered nurse (APRN) were identified and several definitions of an APRN were considered, including the NCSBN and the American Nurses Association (ANA) definitions, as well as others. The characteristics identified aligned closely with these existing definitions. The definition of an APRN, delineated in this document, includes language that addresses responsibility and accountability for health promotion and the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and non-pharmacologic interventions.The definition of an Advanced Practice Registered Nurse (APRN) is a nurse:who has completed an accredited graduate-level education program preparing him/her for one of the four recognized APRN roles;who has passed a national certification examination that measures APRN, role and population-focused competencies and who maintains continued competence as evidenced by recertification in the role and population through the national certification program;who has acquired advanced clinical knowledge and skills preparing him/her to provide direct care to patients, as well as a component of indirect care; however, the defining factor for all APRNs is that a significant component of the education and practice focuses on direct care of individuals;whose practice builds on the competencies of registered nurses (RNs) by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy;who is educationally prepared to assume responsibility and accountability for health promotion and/or maintenance as well as the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and non-pharmacologic interventions;who has clinical experience of sufficient depth and breadth to reflect the intended license; andP.52who has obtained a license to practice as an APRN in one of the four APRN roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), or certified nurse practitioner (CNP).Advanced practice registered nurses are licensed independent practitioners who are expected to practice within standards established or recognized by a licensing body. Each APRN is accountable to patients, the nursing profession, and the licensing board to comply with the requirements of the state nurse practice act and the quality of advanced nursing care rendered; for recognizing limits of knowledge and experience, planning for the management of situations beyond the APRN’s expertise; and for consulting with or referring patients to other health care providers as appropriate.All APRNs are educationally prepared to provide a scope of services across the health wellness-illness continuum to at least one population focus as defined by nationally recognized role and population-focused competencies; however, the emphasis and implementation within each APRN role varies. The services or care provided by APRNs is not defined or limited by setting but rather by patient care needs. The continuum encompasses the range of health states from homeostasis (or wellness) to a disruption in the state of health in which basic needs are not met or maintained (illness), with health problems of varying acuity occurring along the continuum that must be prevented or resolved to maintain wellness or an optimal level of functioning (WHO, 2006). Although all APRNs are educationally prepared to provide care to patients across the health wellness-illness continuum, the emphasis and how implemented within each APRN role varies.The Certified Registered Nurse AnesthetistThe Certified Registered Nurse Anesthetist is prepared to provide the full spectrum of patients’ anesthesia care and anesthesia-related care for individuals across the lifespan, whose health status may range from healthy through all recognized levels of acuity, including persons with immediate, severe, or life-threatening illnesses or injury. This care is provided in diverse settings, including hospital surgical suites and obstetrical delivery rooms; critical access hospitals; acute care; pain management centers; ambulatory surgical centers; and the offices of dentists, podiatrists, ophthalmologists, and plastic surgeons.The Certified Nurse-MidwifeThe certified nurse-midwife provides a full range of primary health care services to women throughout the lifespan, including gynecologic care, family planning services, preconception care, prenatal and postpartum care, childbirth, and care of the newborn. The practice includes treating the male partner of their female clients for sexually transmitted disease and reproductive health. This care is provided in diverse settings, which may include home, hospital, birth center, and a variety of ambulatory care settings including private offices and community and public health clinics.The Clinical Nurse SpecialistThe CNS has a unique APRN role to integrate care across the continuum and through three spheres of influence: patient, nurse, system. The three spheres are overlapping and interrelated but each sphere possesses a distinctive focus. In each of the spheres of influence, the primary goal of the CNS is continuous improvement of patient outcomes and nursing care. Key elements of CNS practice are to create environments through mentoring and P.53system changes that empower nurses to develop caring, evidence-based practices to alleviate patient distress, facilitate ethical decision-making, and respond to diversity. The CNS is responsible and accountable for diagnosis and treatment of health/illness states, disease management, health promotion, and prevention of illness and risk behaviors among individuals, families, groups, and communities.The Certified Nurse PractitionerFor the certified nurse practitioner (CNP), care along the wellness-illness continuum is a dynamic process in which direct primary and acute care is provided across settings. CNPs are members of the health delivery system, practicing autonomously in areas as diverse as family practice, pediatrics, internal medicine, geriatrics, and women’s health care. CNPs are prepared to diagnose and treat patients with undifferentiated symptoms as well as those with established diagnoses. Both primary and acute care CNPs provide initial, ongoing, and comprehensive care, includes taking comprehensive histories, providing physical examinations and other health assessment and screening activities, and diagnosing, treating, and managing patients with acute and chronic illnesses and diseases. This includes ordering, performing, supervising, and interpreting laboratory and imaging studies; prescribing medication and durable medical equipment; and making appropriate referrals for patients and families. Clinical CNP care includes health promotion, disease prevention, health education, and counseling as well as the diagnosis and management of acute and chronic diseases. Certified nurse practitioners are prepared to practice as primary care CNPs and acute care CNPs, which have separate national consensus-based competencies and separate certification processes.TitlingThe title Advanced Practice Registered Nurse (APRN) is the licensing title to be used for the subset of nurses prepared with advanced, graduate-level nursing knowledge to provide direct patient care in four roles: certified registered nurse anesthetist, certified nurse-midwife, clinical nurse specialist, and certified nurse practitioner.4 This title, APRN, is a legally protected title. Licensure and scope of practice are based on graduate education in one of the four roles and in a defined population.Verification of licensure, whether hard copy or electronic, will indicate the role and population for which the APRN has been licensed.At a minimum, an individual must legally represent themselves, including in a legal signature, as an APRN and by the role. He/she may indicate the population as well. No one, except those who are licensed to practice as an APRN, may use the APRN title or any of the APRN role titles. An individual also may add the specialty title in which they are professionally recognized in addition to the legal title of APRN and role.P.54Diagram 1: APRN Regulatory ModelUnder this APRN Regulatory Model, there are four roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), and certified nurse practitioner (CNP). These four roles are given the title of advanced practice registered nurse (APRN). APRNs are educated in one of the four roles and in at least one of six population foci: family/individual across the lifespan, adult-gerontology, neonatal, pediatrics, women’s health/gender-related or psych/mental health. Individuals will be licensed as independent practitioners for practice at the level of one of the four APRN roles within at least one of the six identified population foci. Education, certification, and licensure of an individual must be congruent in terms of role and population foci. APRNs may specialize but they can not be licensed solely within a specialty area. Specialties can provide depth in one’s practice within the established population foci.* The population focus, adult-gerontology, encompasses the young adult to the older adult, including the frail elderly. APRNs educated and certified in the adult-gerontology population are educated and certified across both areas of practice and will be titled Adult-Gerontology CNP or CNS. In addition, all APRNs in any of the four roles providing care to the adult population, e.g., family or gender specific, must be prepared to meet the growing needs of the older adult population. Therefore, the education program should include didactic and clinical education experiences necessary to prepare APRNs with these enhanced skills and knowledge. ** The population focus, psychiatric/mental health, encompasses education and practice across the lifespan. ++ The Clinical Nurse Specialist (CNS) is educated and assessed through national certification processes across the continuum from wellness through acute care.P.55Broad-based APRN EducationFor entry into APRN practice and for regulatory purposes, APRN education must:be formal education with a graduate degree or post-graduate certificate (either post-master’s or post-doctoral) that is awarded by an academic institution and accredited by a nursing or nursing-related accrediting organization recognized by the U.S. Department of Education (USDE) and/or the Council for Higher Education Accreditation (CHEA);be awarded pre-approval, pre-accreditation, or accreditation status prior to admitting students;be comprehensive and at the graduate level;prepare the graduate to practice in one of the four identified APRN roles;prepare the graduate with the core competencies for one of the APRN roles across at least one of the six population foci;include at a minimum, three separate comprehensive graduate-level courses (the APRN Core) in:Advanced physiology/pathophysiology, including general principles that apply across the lifespan;Advanced health assessment, which includes assessment of all human systems, advanced assessment techniques, concepts and approaches; andAdvanced pharmacology, which includes pharmacodynamics, pharmacokinetics and pharmacotherapeutics of all broad categories of agents.Additional content, specific to the role and population, in these three APRN core areas should be integrated throughout the other role and population didactic and clinical courses;Provide a basic understanding of the principles for decision making in the identified role;Prepare the graduate to assume responsibility and accountability for health promotion and/or maintenance as well as the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and non-pharmacologic interventions; andEnsure clinical and didactic coursework is comprehensive and sufficient to prepare the graduate to practice in the APRN role and population focus.Preparation in a specialty area of practice is optional but if included must build on the APRN role/population-focus competencies. Clinical and didactic coursework must be comprehensive and sufficient to prepare the graduate to obtain certification for licensure in and to practice in the APRN role and population focus.As part of the accreditation process, all APRN education programs must undergo a pre-approval, pre-accreditation, or accreditation process prior to admitting students. The purpose of the pre-approval process is twofold: 1) to ensure that students graduating from the program will be able to meet the education criteria necessary for national certification in the role and population-focus and if successfully certified, are eligible for licensure to practice in the APRN role/population-focus; and 2) to ensure that programs will meet all educational standards prior to starting the program. The pre-approval, pre-accreditation or accreditation processes may vary across APRN roles.P.56APRN SpecialtiesPreparation in a specialty area of practice is optional, but if included must build on the APRN role/population-focused competencies. Specialty practice represents a much more focused area of preparation and practice than does the APRN role/population focus level. Specialty practice may focus on specific patient populations beyond those identified or health care needs such as oncology, palliative care, substance abuse, or nephrology. The criteria for defining an APRN specialty is built upon the ANA (2004) Criteria for Recognition as a Nursing Specialty (see Appendix B). APRN specialty education and practice build upon and are in addition to the education and practice of the APRN role and population focus. For example, a family CNP could specialize in elder care or nephrology; an Adult-Gerontology CNS could specialize in palliative care; a CRNA could specialize in pain management; or a CNM could specialize in care of the post-menopausal woman. State licensing boards will not regulate the APRN at the level of specialties in this APRN Regulatory Model. Professional certification in the specialty area of practice is strongly recommended.An APRN specialtypreparation cannot replace educational preparation in the role or one of the six population foci;preparation can not expand one’s scope of practice beyond the role or population focusaddresses a subset of the population-focus;title may not be used in lieu of the licensing title, which includes the role or role/population; andis developed, recognized, and monitored by the profession.New specialties emerge based on health needs of the population. APRN specialties develop to provide added value to the role practice as well as providing flexibility within the profession to meet these emerging needs of patients. Specialties also may cross several or all APRN roles. A specialty evolves out of an APRN role/population focus and indicates that an APRN has additional knowledge and expertise in a more discrete area of specialty practice. Competency in the specialty areas could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (e.g., portfolios, examinations, etc.).Education programs may concurrently prepare individuals in a specialty providing they meet all of the other requirements for APRN education programs, including preparation in the APRN core, role, and population core competencies. In addition, for licensure purposes, one exam must assess the APRN core, role, and population-focused competencies. For example, a nurse anesthetist would write one certification examination, which tests the APRN core, CRNA role, and population-focused competencies, administered by the Council on Certification for Nurse Anesthetist; or a primary care family nurse practitioner would write one certification examination, which tests the APRN core, CNP role, and family population-focused competencies, administered by ANCC or AANP. Specialty competencies must be assessed separately. In summary, education programs preparing individuals with this additional knowledge in a specialty, if used for entry into advanced practice registered nursing and for regulatory purposes, must also prepare individuals in one of the four nationally recognized APRN roles and in one of the six population foci. Individuals must be P.57recognized and credentialed in one of the four APRN roles within at least one population foci. APRNs are licensed at the role/population focus level and not at the specialty level. However, if not intended for entry-level preparation in one of the four roles/population foci and not for regulatory purposes, education programs, using a variety of formats and methodologies, may provide licensed APRNs with the additional knowledge, skills, and abilities, to become professionally certified in the specialty area of APRN practice.Emergence of New APRN Roles and Population-FociAs nursing practice evolves and health care needs of the population change, new APRN roles or population-foci may evolve over time. An APRN role would encompass a unique or significantly differentiated set of competencies from any of the other APRN roles. In addition, the scope of practice within the role or population focus is not entirely subsumed within one of the other roles. Careful consideration of new APRN roles or population-foci is in the best interest of the profession.For licensure, there must be clear guidance for national recognition of a new APRN role or population-focus. A new role or population focus should be discussed and vetted through the national licensure, accreditation, certification, education communication structure: LACE. An essential part of being recognized as a role or population-focus is that educational standards and practice competencies must exist, be consistent, and must be nationally recognized by the profession. Characteristics of the process to be used to develop nationally recognized core competencies, and education and practice standards for a newly emerging role or population-focus are:national in scopeinclusivetransparentaccountableinitiated by nursingconsistent with national standards for licensure, accreditation, certification and educationevidence-basedconsistent with regulatory principles.To be recognized, an APRN role must meet the following criteria:nationally recognized education standards and core competencies for programs preparing individuals in the role;education programs, including graduate degree granting (master’s, doctoral) and post-graduate certificate programs, are accredited by a nursing or nursing-related accrediting organization that is recognized by the U.S. Department of Education (USDE) and/or the Council for Higher Education Accreditation (CHEA); andprofessional nursing certification program that is psychometrically sound, legally defensible, and which meets nationally recognized accreditation standards for certification programs.5P.58View FigureDiagram 2: Relationship Among Educational Competencies, Licensure, & Certification in the Role/Population Foci and Education and Credentialing in a SpecialtyIMPLEMENTATION STRATEGIES FOR APRN REGULATORY MODELIn order to accomplish the above model, the four prongs of regulation: licensure, accreditation, certification, and education (LACE) must work together. Expectations for licensure, accreditation, certification, and education are listed below:Foundational Requirements for LicensureBoards of nursing will:license APRNs in the categories of Certified Registered Nurse Anesthetist, Certified Nurse-Midwife, Clinical Nurse Specialist or Certified Nurse Practitioner within a specific population focus;be solely responsible for licensing Advanced Practice Registered Nurses6;only license graduates of accredited graduate programs that prepare graduates with the APRN core, role and population competencies;require successful completion of a national certification examination that assesses APRN core, role and population competencies for APRN licensure.not issue a temporary license;only license an APRN when education and certification are congruent;license APRNs as independent practitioners with no regulatory requirements for collaboration, direction or supervision;allow for mutual recognition of advanced practice registered nursing through the APRN Compact;P.59have at least one APRN representative position on the board and utilize an APRN advisory committee that includes representatives of all four APRN roles; and,institute a grandfathering7 clause that will exempt those APRNs already practicing in the state from new eligibility requirements.Foundational Requirements for Accreditation of Education ProgramsAccreditors will:be responsible for evaluating APRN education programs including graduate degree-granting and post-graduate certificate programs.8.through their established accreditation standards and process, assess APRN education programs in light of the APRN core, role core, and population core competencies;assess developing APRN education programs and tracks by reviewing them using established accreditation standards and granting pre-approval, pre-accreditation, or accreditation prior to student enrollment;include an APRN on the visiting team when an APRN program/track is being reviewed; andmonitor APRN educational programs throughout the accreditation period by reviewing them using established accreditation standards and processes.Foundational Requirements for CertificationCertification programs providing APRN certification used for licensure will:follow established certification testing and psychometrically sound, legally defensible standards for APRN examinations for licensure (see appendix A for the NCSBN Criteria for APRN Certification Programs);assess the APRN core and role competencies across at least one population focus of practice;assess specialty competencies, if appropriate, separately from the APRN core, role and population-focused competencies;be accredited by a national certification accreditation body;9P.60enforce congruence (role and population focus) between the education program and the type of certification examination;provide a mechanism to ensure ongoing competence and maintenance of certification;participate in ongoing relationships which make their processes transparent to boards of nursing;participate in a mutually agreeable mechanism to ensure communication with boards of nursing and schools of nursing.Foundational Requirements for EducationAPRN education programs/tracks leading to APRN licensure, including graduate degree-granting and post-graduate certificate programs will:follow established educational standards and ensure attainment of the APRN core, role core and population core competencies.10,11be accredited by a nursing accrediting organization that is recognized by the U.S. Department of Education (USDE) and/or the Council for Higher Education Accreditation (CHEA).12be pre-approved, pre-accredited, or accredited prior to the acceptance of students, including all developing APRN education programs and tracks;ensure that graduates of the program are eligible for national certification and state licensure; andensure that official documentation (e.g., transcript) specifies the role and population focus of the graduate.Communication StrategiesA formal communication mechanism, LACE, which includes those regulatory organizations that represent APRN licensure, accreditation, certification, and education entities would be created. The purpose of LACE would be to provide a formal, ongoing communication mechanism that provides for transparent and aligned communication among the identified entities. The collaborative efforts between the APRN Consensus Group and the NCSBN APRN Advisory Panel, through the APRN Joint Dialogue Group have illustrated the ongoing level of communication necessary among these groups to ensure that all APRN stakeholders are involved. Several strategies including equal representation on an integrated board with P.61face-to-face meetings, audio and teleconferencing, pass-protected access to agency web sites, and regular reporting mechanisms have been recommended. These strategies will build trust and enhance information sharing. Examples of issues to be addressed by the group would be: guaranteeing appropriate representation of APRN roles among accreditation site visitors, documentation of program completion by education institutions, notification of examination outcomes to educators and regulators, notification of disciplinary action toward licensees by boards of nursing.Creating the LACE Structure and ProcessesSeveral principles should guide the formulation of a structure including: 1) all four entities of LACE should have representation; 2) the total should allow effective discussion of and response to issues and ; 3) the structure should not be duplicative of existing structures such as the Alliance for APRN Credentialing. Consideration should be given to evolving the existing Alliance structure to meet the needs of LACE. Guidance from an organizational consultant will be useful in forming a permanent structure that will endure and support the work that needs to continue. The new structure will support fair decision-making among all relevant stakeholders. In addition, the new structure will be in place as soon as possible.The LACE organizational structure should include representation of:State licensing boards, including at least one compact and one non-compact state;Accrediting bodies that accredit education programs of the four APRN roles;Certifying bodies that offer APRN certification used for regulatory purposes; and,Education organizations that set standards for APRN education.Timeline for Implementation of Regulatory ModelImplementation of the recommendations for an APRN Regulatory Model will occur incrementally. Due to the interdependence of licensure, accreditation, certification, and education, certain recommendations will be implemented sequentially. However, recognizing that this model was developed through a consensus process with participation of APRN certifiers, accreditors, public regulators, educators, and employers, it is expected that the recommendations and model delineated will inform decisions made by each of these entities as the APRN community moves to fully implement the APRN Regulatory Model. A target date for full implementation of the Regulatory Model and all embedded recommendations is the Year 2015.HISTORICAL BACKGROUNDNCSBN APRN Committee (previously APRN Advisory Panel)NCSBN became involved with advanced practice nursing when boards of nursing began using the results of APRN certification examinations as one of the requirements for APRN licensure. During the 1993 NCSBN annual meeting, delegates adopted a position paper on the licensure of advanced nursing practice which included model legislation language and model administrative rules for advanced nursing practice. NCSBN core competencies for certified nurse practitioners were adopted the following year.P.62In 1995, NCSBN was directed by the Delegate Assembly to work with APRN certifiers to make certification examinations suitable for regulatory purposes. Since then, much effort has been made toward that purpose. During the mid and late 90’s, the APRN certifiers agreed to undergo accreditation and provide additional information to boards of nursing to ensure that their examinations were psychometrically sound and legally defensible (NCSBN, 1998).During the early 2000s, the APRN Advisory Panel developed criteria for ARPN certification programs and for accreditations agencies. In January 2002, the board of directors approved the criteria and process for a new review process for APRN certification programs. The criteria represented required elements of certification programs that would result in a legally defensible examination suitable for the regulation of advanced practice nurses. Subsequently, the APRN Advisory Panel has worked with certification programs to improve the legal defensibility of APRN certification examinations and to promote communication with all APRN stakeholders regarding APRN regulatory issues such as with the establishment of the annual NCSBN APRN Roundtable in the mid 1990’s. In 2002, the Advisory Panel also developed a position paper describing APRN regulatory issues of concern.In 2003, the APRN Advisory Panel began a draft APRN vision paper in an attempt to resolve APRN regulatory concerns such as the proliferation of APRN subspecialty areas. The purpose of the APRN Vision Paper was to provide direction to boards of nursing regarding APRN regulation for the next 8-10 years by identifying an ideal future APRN regulatory model. Eight recommendations were made. The draft vision paper was completed in 2006. After reviewing the draft APRN vision paper at their February 2006 board meeting, the board of directors directed that the paper be disseminated to boards of nursing and APRN stakeholders for feedback. The Vision paper also was discussed during the 2006 APRN Roundtable. The large response from boards of nursing and APRN stakeholders was varied. The APRN Advisory Panel spent the remaining part of 2006, reviewing and discussing the feedback with APRN stakeholders. (See Appendix C for the list of APRN Advisory Panel members who worked on the draft APRN Vision Paper and Appendix D for the list of organizations represented at the 2006 APRN Roundtable where the draft vision paper was presented.)APRN Consensus GroupIn March 2004, the American Association of Colleges of Nursing (AACN) and the National Organization of Nurse Practitioner Faculties (NONPF) submitted a proposal to the Alliance for Nursing Accreditation, now named Alliance for APRN Credentialing13 (hereafter referred to as the APRN Alliance) to establish a process to develop a consensus14 statement on the credentialing of advanced practice nurses (APNs).15 The APRN Alliance16, created in 1997,was convened by AACN to regularly discuss issues related to nursing education, practice, and credentialing. A number of differing views on how APN practice is defined, what constitutes specialization versus subspecialization, and the appropriate credentialing requirements that would authorize practice had emerged over the past several years.An invitation to participate in a national APN consensus process was sent to 50 organizations that were identified as having an interest in advanced practice nursing (see Appendix F). Thirty-two organizations participated in the APN Consensus Conference in Washington, D.C. June 2004. The focus of the one-day meeting was to initiate an in-depth examination of issues related to APN definition, specialization, sub-specialization, and regulation, which includes accreditation, education, certification, and licensure17. Based on recommendations generated in the June 2004 APN Consensus Conference, the Alliance formed a smaller work group made up of designees from 23 organizations with broad representation of APN certification, licensure, education, accreditation, and practice. The charge to the work group was to develop a statement that addresses the issues, delineated during the APN Consensus Conference with the goal of envisioning a future model for APNs. The Alliance APN Consensus Work Group (hereafter referred to as the Work Group) convened for 16 days of intensive discussion between October 2004 and July 2007 (see Appendix H for a list of organizations represented on the APN Work Group).In December 2004, the American Nurses Association (ANA) and AACN co-hosted an APN stakeholder meeting to address those issues identified at the June 2004 APN Consensus meeting. Attendees agreed to ask the APN Work Group to continue to craft a consensus statement that would include recommendations regarding APN regulation, specialization, and subspecialization. It also was agreed that organizations in attendance who had not participated in the June 2004 APN Consensus meeting would be included in the APN Consensus Group and that this larger group would reconvene at a future date to discuss the recommendations of the APN Work Group.Following the December 2004 APN Consensus meeting, the Work Group continued to work diligently to reach consensus on the issues surrounding APRN education, practice, accreditation, certification, and licensure, and to create a future consensus-based model for APRN regulation. Subsequent APRN Consensus Group meetings were held in September 2005 and June 2006. All organizations who participated in the APRN Consensus Group are listed in Appendix G.P.64APRN Joint Dialogue GroupIn April, 2006, the APRN Advisory Panel met with the APRN Consensus Work Group to discuss APRN issues described in the NCSBN draft vision paper. The APRN Consensus Work Group requested and was provided with feedback from the APRN Advisory Panel regarding the APRN Consensus Group Report. Both groups agreed to continue to dialogue.As the APRN Advisory Panel and APRN Consensus Work Group continued their work in parallel fashion, concerns regarding the need for each group’s work not to conflict with the other were expressed. A subgroup of seven people from the APRN Consensus Work Group and seven individuals from the APRN Advisory Panel were convened in January, 2007. The group called itself the APRN Joint Dialogue Group (see Appendix E) and the agenda consisted of discussing areas of agreement and disagreement between the two groups. The goal of the subgroup meetings was anticipated to be two papers that did not conflict, but rather complemented each other. However, as the APRN Joint Dialogue Group continued to meet, much progress was made regarding areas of agreement; it was determined that rather than two papers being disseminated, one joint paper would be developed, which reflected the work of both groups. This document is the product of the work of the APRN Joint Dialogue Group and through the consensus-based work of the APRN Consensus Work Group and the NCSBN APRN Advisory Committee.Assumptions Underlying the Work of the Joint Dialogue GroupThe consensus-based recommendations that have emerged from the extensive dialogue and consensus-based processes delineated in this report are based on the following assumptions:Recommendations must address current issues facing the advanced practice registered nurse (APRN) community but should be future oriented.The ultimate goal of licensure, accreditation, certification, and education is to promote patient safety and public protection.The recognition that this document was developed with the participation of APRN certifiers, accreditors, public regulators, educators, and employers. The intention is that the document will allow for informed decisions made by each of these entities as they address APRN issues.CONCLUSIONThe recommendations offered in this paper present an APRN regulatory model as a collaborative effort among APRN educators, accreditors, certifiers, and licensure bodies. The essential elements of APRN regulation are identified as licensure, accreditation, certification, and education. The recommendations reflect a need and desire to collaborate among regulatory bodies to achieve a sound model and continued communication with the goal of increasing the clarity and uniformity of APRN regulation.The goals of the consensus processes were to:strive for harmony and common understanding in the APRN regulatory community that would continue to promote quality APRN education and practice;develop a vision for APRN regulation, including education, accreditation, certification, and licensure;P.65establish a set of standards that protect the public, improve mobility, and improve access to safe, quality APRN care; andproduce a written statement that reflects consensus on APRN regulatory issues.In summary, this report includes: a definition of the APRN Regulatory Model, including a definition of the Advanced Practice Registered Nurse; a definition of broad-based APRN education; a model for regulation that ensures APRN education and certification as a valid and reliable process, that is based on nationally recognized and accepted standards; uniform recommendations for licensing bodies across states; a process and characteristics for recognizing a new APRN role; and a definition of an APRN specialty that allows for the profession to meet future patient and nursing needs.The work of the Joint Dialogue Group in conjunction with all organizations representing APRN licensure, accreditation, certification, and education to advance a regulatory model is an ongoing collaborative process that is fluid and dynamic. As health care evolves and new standards and needs emerge, the APRN Regulatory Model will advance accordingly to allow APRNs to care for patients in a safe environment to the full potential of their nursing knowledge and skill.P.66REFERENCESAmerican Association of Colleges of Nursing. (1996). The Essentials of Master’s Education for Advanced Practice Nursing Education. Washington, DC: AuthorAmerican Association of Colleges of Nursing. (2004). Position Statement on the Practice Doctorate in Nursing. Washington, DC: Author. Accessed at http://www.aacn.nche.edu/DNP/DNPPositionStatement.htm.American Association of Colleges of Nursing. (2006). The Essentials of Doctoral Education for Advanced Nursing Practice. Washington, DC: Author.American College of Nurse-Midwives (2002). Core Competencies for Basic Midwifery Practice. 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Can be accessed at http://www.who.int/healthpromotion/about/HP%20Glossay%20in%20HPI.pdfAPPENDIX ANCSBN CRITERIA FOR EVALUATING CERTIFICATION PROGRAMSCriteriaElaborationI. The program is national in the scope of its credentialing.The advanced nursing practice category and standards of practice have been identified by national organizations.Credentialing services are available to nurses throughout the United States and its territories.There is a provision for public representation on the certification board.A nursing specialty organization that establishes standards for the nursing specialty exists.A tested body of knowledge related to the advanced practice nursing specialty exists.The certification board is an entity with organizational autonomy.II. Conditions for taking the examination are consistent with acceptable standards of the testing community.Applicants do not have to belong to an affiliated professional organization in order to apply for certification offered by the certification program.Eligibility criteria rationally related to competence to practice safely.Published criteria are enforced.In compliance with the American Disabilities Act.Sample application(s) are available.Certification requirements includedApplication procedures include:procedures for ensuring match between education and clinical experience, and APRN specialty being certified,procedures for validating information provided by candidate,procedures for handling omissions and discrepanciesProfessional staff responsible for credential review and admission decisions.Examination should be administered frequently enough to be accessible but not so frequently as to over-expose items.Periodic review of eligibility criteria and application procedures to ensure that they are fair and equitable.III. Educational requirements are consistent with the requirements of the advanced practice specialty.Current U.S. registered nurse licensure is required.Graduation from a graduate advanced practice education program meets the following requirements:Education program offered by an accredited college or university offers a graduate degree with a concentration in the advanced nursing practice specialty the individual is seekingIf post-masters certificate programs are offered, they must be offered through institutions meeting criteria B.1.Both direct and indirect clinical supervision must be congruent with current national specialty organizations and nursing accreditation guidelinesThe curriculum includes, but is not limited to:biological, behavioral, medical, and nursing sciences relevant to practice as an APRN in the specified category;legal, ethical, and professional responsibilities of the APRN; andsupervised clinical practice relevant to the specialty of APRNThe curriculum meets the following criteria:Curriculum is consistent with competencies of the specific areas of practiceInstructional track/major has a minimum of 500 supervised clinical hours overallThe supervised clinical experience is directly related to the knowledge and role of the specialty and categoryAll individuals, without exception, seeking a national certification must complete a formal didactic and clinical advanced practice program meeting the above criteria.IV. The standard methodologies used are acceptable to the testing community such as incumbent job analysis study, logical job analysis studies.Exam content based on a job/task analysis.Job analysis studies are conducted at least every five years.The results of the job analysis study are published and available to the public.There is evidence of the content validity of the job analysis study.V. The examination represents entry-level practice in the advanced nursing practice category.Entry-level practice in the advanced practice specialty is described including the following:ProcessFrequencyQualifications of the group making the determinationGeographic representationProfessional or regulatory organizations involved in the reviewsVI. The examination represents the knowledge, skills, and abilities essential for the delivery of safe and effective advanced nursing care to the clients.The job analysis includes activities representing knowledge, skills, and abilities necessary for competent performance.The examination reflects the results of the job analysis study.Knowledge, skills, and abilities, which are critical to public safety, are identified.The examination content is oriented to educational curriculum practice requirements and accepted standards of care.VII. Examination items are reviewed for content validity, cultural bias, and correct scoring using an established mechanism, both before use and periodically.Each item is associated with a single cell of the test plan.Items are reviewed for currency before each use at least every three years.Items are reviewed by members of under-represented gender and ethnicities who are active in the field being certified. Reviewers have been trained to distinguish irrelevant cultural dependencies from knowledge necessary to safe and effective practice. Process for identifying and processing flagged items is identified.A statistical bias analysis is performed on all items.All items are subjected to an “unscored” use for data collection purposes before their first use as a “scored” item.A process to detect and eliminate bias from the test is in place.Reuse guidelines for items on an exam form are identified.Item writing and review is done by qualified individuals who represent specialties, population subgroups, etc.VIII. Examinations are evaluated for psychometric performance.Reference groups used for comparative analysis are defined.IX. The passing standard is established using acceptable psychometric methods, and is re-evaluated periodically.Passing standard is criterion-referenced.X. Examination security is maintained through established procedures.Protocols are established to maintain security related to:Item development (e.g., item writers and confidentiality, how often items are re-used)Maintenance of question poolPrinting and production processStorage and transportation of examination is secureAdministration of examination (e.g., who administers, who checks administrators)Ancillary materials (e.g., test keys, scrap materials)Scoring of examinationOccurrence of a crisis (e.g., exam is compromised, etc)XI. Certification is issued based upon passing the examination and meeting all other certification requirements.Certification process is described, including the following:Criteria for certification decisions are identifiedThe verification that passing exam results and all other requirements are metProcedures are in place for appealing decisionsThere is due process for situations such as nurses denied access to the examination or nurses who have had their certification revoked.A mechanism is in place for communicating with candidate.Confidentiality of nonpublic candidate data is maintained.XII. A retake policy is in place.Failing candidates permitted to be reexamined at a future date.Failing candidates informed of procedures for retakes.Test for repeating examinees should be equivalent to the test for first time candidates.Repeating examinees should be expected to meet the same test performance standards as first time examinees.Failing candidates are given information on content areas of deficiency.Repeating examinees are not exposed to the same items when taking the exam previously.XIII. Certification maintenance program, which includes review of qualifications and continued competence, is in place.Certification maintenance requirements are specified (e.g., continuing education, practice, examination, etc.).Certification maintenance procedures include:Procedures for ensuring match between continued competency measures and APRN specialtyProcedures for validating information provided by candidatesProcedures for issuing re-certificationProfessional staff oversee credential review.Certification maintenance is required a minimum of every 5 years.XIV. Mechanisms are in place for communication to boards of nursing for timely verification of an individual’s certification status, changes in certification status, and changes in the certification program, including qualifications, test plan and scope of practice.Communication mechanisms address:Permission obtained from candidates to share information regarding the certification processProcedures to provide verification of certification to Boards of NursingProcedures for notifying Boards of Nursing regarding changes of certification statusProcedures for notification of changes in certification programs (qualifications, test plan or scope of practice) to Boards of NursingXV. An evaluation process is in place to provide quality assurance in its certification program.Internal review panels are used to establish quality assurance procedures.Composition of these groups (by title or area of expertise) is describedProcedures are reviewedFrequency of reviewProcedures are in place to ensure adherence to established QA policy and procedures.P.73APPENDIX BAmerican Nurses Association Congress on Nursing Practice and Economics 2004 Recognition as a Nursing SpecialtyThe process of recognizing an area of practice as a nursing specialty allows the profession to formally identify subset areas of focused practice. A clear description of that nursing practice assists the larger community of nurses, healthcare consumers, and others to gain familiarity and understanding of the nursing specialty. Therefore, the document requesting ANA recognition must clearly and fully address each of the fourteen specialty recognition criteria. The inclusion of additional materials to support the discussion and promote understanding of the criteria is acceptable. A scope of practice statement must accompany the submission requesting recognition as a nursing specialty.Criteria for Recognition as a Nursing SpecialtyThe following criteria are used by the Congress on Nursing Practice and Economics in the review and decision-making processes to recognize an area of practice as a nursing specialty:A nursing specialty:Defines itself as nursing.Adheres to the overall licensure requirements of the profession.Subscribes to the overall purposes and functions of nursing.Is clearly defined.Is practiced nationally or internationally.Includes a substantial number of nurses who devote most of their practice to the specialty.Can identify a need and demand for itself.Has a well derived knowledge base particular to the practice of the nursing specialty.Is concerned with phenomena of the discipline of nursing.Defines competencies for the area of nursing specialty practice.Has existing mechanisms for supporting, reviewing and disseminating research to support its knowledge base.Has defined educational criteria for specialty preparation or graduate degree.Has continuing education programs or continuing competence mechanisms for nurses in the specialty.Is organized and represented by a national specialty association or branch of a parent organization.P.74APPENDIX CNCBN APRN Committee Members 2003 -20082003Katherine Thomas, Executive Director, Texas Board of Nurse ExaminersPatty Brown, Board Staff, Kansas State Board of NursingKim Powell, Board President, Montana Board of NursingCharlene Hanson, ConsultantGeorgia Manning, Arkansas State Board of NursingDeborah Bohannon-Johnson, Board President, North Dakota Board of NursingJane Garvin, Board President, Maryland Board of NursingJanet Younger, Board President, Virginia Board of NursingNancy Chornick, NCSBN2004Katherine Thomas, Executive Director, Texas Board of Nurse ExaminersPatty Brown, Board Staff, Kansas State Board of NursingKim Powell, Board President, Montana Board of NursingCharlene Hanson, ConsultantJanet Younger, Board President, Virginia Board of NursingPolly Johnson, Board Representative, North Carolina Board of NursingLaura Poe, Member, Utah State Board of NursingGeorgia Manning, Arkansas State Board of NursingJane Garvin RN, Board President, Maryland Board of NursingAnn Forbes, Board Staff, North Carolina Board of NursingNancy Chornick, NCSBN2005Katherine Thomas, Executive Director, Texas Board of Nurse ExaminersPatty Brown, Board Staff, Kansas State Board of NursingCharlene Hanson, ConsultantJanet Younger, Board President, Virginia Board of NursingPolly Johnson, Board Representative, North Carolina Board of NursingLaura Poe, Member, Utah State Board of NursingMarcia Hobbs, Board Member, Kentucky Board of NursingRandall Hudspeth, Board Member, Idaho Board of NursingAnn Forbes, Board Staff, North Carolina Board of NursingCristiana Rosa, Board Member, Rhode Island Board of NurseKim Powell, Board President, Montana Board of NursingNancy Chornick, NCSBN2006Katherine Thomas, Executive Director, Texas Board of Nurse ExaminersPatty Brown, Board Staff, Kansas State Board of NursingCharlene Hanson, ConsultantJanet Younger, Board President, Virginia Board of NursingLaura Poe, Member, Utah State Board of NursingP.75Marcia Hobbs, Board Member, Kentucky Board of NursingRandall Hudspeth, Board Member, Idaho Board of NursingCristiana Rosa, Board Member, Rhode Island Board of NurseJames Luther Raper, Board Member, Alabama Board of NursingLinda Rice, Board Member, Vermont Board of NursingCathy Williamson, Board Member, Mississippi Board of NursingAnn Forbes, Board Staff, North Carolina Board of NursingPolly Johnson, Board Representative, North Carolina Board of NursingSheila N. Kaiser, Board Vice-Chair, Massachusetts Board of Registration in NursingNancy Chornick, NCSBN2007Faith Fields, Board Liaison, Arkansas State Board of NursingKatherine Thomas, Executive Director, Texas Board of Nurse ExaminersAnn L. O’Sullivan, Board Member, Pennsylvania Board of NursingPatty Brown, Board Staff, Kansas State Board of NursingCharlene Hanson, ConsultantLaura Poe, Member, Utah State Board of NursingJohn C. Preston, Board Member, Tennessee Board of NursingRandall Hudspeth, Board Member, Idaho Board of NursingCristiana Rosa, Board Member, Rhode Island Board of NurseJames Luther Raper, Board Member, Alabama Board of NursingLinda Rice, Board Member, Vermont Board of NursingCathy Williamson, Board Member, Mississippi Board of NursingJanet Younger, Board President, Virginia Board of NursingMarcia Hobbs, Board Member, Kentucky Board of NursingNancy Chornick, NCSBN2008Doreen K. Begley, Board Member, Nevada State Board of NursingAnn L. O’Sullivan, Board Member, Pennsylvania Board of NursingPatty Brown, Board Staff, Kansas State Board of NursingCharlene Hanson, ConsultantLaura Poe, Member, Utah State Board of NursingJohn C. Preston, Board Member, Tennessee Board of NursingRandall Hudspeth, Board Member, Idaho Board of NursingCristiana Rosa, Board Member, Rhode Island Board of NurseJames Luther Raper, Board Member, Alabama Board of NursingLinda Rice, Board Member, Vermont Board of NursingCathy Williamson, Board Member, Mississippi Board of NursingTracy Klein, Member Staff, Oregon State Board of NursingDarlene Byrd, Board Member, Arkansas State Board of NursingNancy Chornick, NCSBNP.76Appendix D2006 NCSBN APRN Roundtable Organization Attendance ListAlabama Board of NursingAmerican Academy of Nurse PractitionersAmerican Academy of Nurse Practitioners National Certification Program, IncAmerican Association of Colleges of NursingAmerican Association of Critical-Care NursesAmerican Association of Nurse AnesthetistsAmerican Association of Psychiatric NursesAmerican Board of Nursing SpecialtiesAmerican College of Nurse PractitionersAmerican College of Nurse-MidwivesAmerican Holistic Nurses’ Certification CorporationAmerican Midwifery Certification BoardAmerican Nurses AssociationAmerican Nurses Credentialing CenterAmerican Organization of Nurses ExecutivesAssociation of Women’s Health, Obstetric and Neonatal NursesBoard of Certification for Emergency NursingCouncil on Accreditation of Nurse Anesthesia Educational ProgramsEmergency Nurses AssociationGeorge Washington School of MedicineIdaho Board of NursingKansas Board of NursingKentucky Board of NursingMassachusetts Board of NursingMississippi Board of NursingNational Association of Clinical Nurse SpecialistsNational Association of Nurse Practitioners in Women’s HealthNational Association of Pediatric Nurse PractitionersNational Board for Certification of Hospice & Palliative NursesNational Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing SpecialtiesNational League for Nursing Accrediting CommissionP.77North Carolina Board of NursingOncology Nursing Certification CorporationPediatric Nursing Certification BoardRhode Island Board of NursingTexas Board of Nurse ExaminersUtah Board of NursingVermont Board of NursingWound, Ostomy and Continence Nursing Certification Board2007 APRN Roundtable Attendance ListAmerican Association of Colleges of NursingABNS Accreditation CouncilAlabama Board of NursingAmerican Academy of Nurse PractitionersAmerican Academy of Nurse Practitioners National Certification Program, IncAmerican Association of Critical-Care NursesAmerican Association of Nurse AnesthetistsAmerican College of Nurse-MidwivesAmerican College of Nurse PractitionersAmerican Midwifery Certification BoardAmerican Nurses Credentialing Center – Certification ServicesAmerican Organization of Nurse ExecutivesArkansas State Board of NursingAssociation of Women’s Health, Obstetric and Neonatal NursesBoard of Certification for Emergency NursingColorado Board of NursingCommission on Collegiate Nursing EducationCouncil on Accreditation of Nurse Anesthesia Educational ProgramsCouncil on Certification of Nurse Anesthetists and Council on Recertification of Nurse AnesthetistsEmergency Nurses AssociationIdaho Board of NursingIllinois State Board of NursingKansas Board of NursingKentucky Board of NursingP.78Loyola University Chicago Niehoff School of NursingMinnesota Board of NursingMississippi Board of NursingNational Association of Clinical Nurse SpecialistsNational Association of Pediatric Nurse PractitionersNational League for Nursing Accrediting CommissionNational Organization of Nurse Practitioner FacultiesNational Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing SpecialtiesOncology Nursing Certification CorporationPennsylvania Board of NursingPediatric Nursing Certification BoardRhode Island Board of NursingRush University College of NursingSouth Dakota Board of NursingTennessee Board of NursingTexas Board of Nurse ExaminersVermont Board of NursingP.79APPENDIX EAPRN Joint Dialogue Group Organizations represented at the Joint Dialogue Group MeetingsAmerican Academy of Nurse Practitioners Certification ProgramAmerican Association of Colleges of NursingAmerican Association of Nurse AnesthetistsAmerican College of Nurse-MidwivesAmerican Nurses AssociationAmerican Organization of Nurse ExecutivesCompact AdministratorsNational Association of Clinical Nurse SpecialistsNational League for Nursing Accrediting CommissionNational Organization of Nurse Practitioner FacultiesNational Council of State Boards of NursingNCSBN APRN Advisory Committee Representatives (5)P.80Appendix FORGANIZATIONS INVITED TO APN CONSENSUS CONFERENCE JUNE, 2004Accreditation Commission for Midwifery EducationAmerican Academy of Nurse PractitionersAmerican Academy of Nurse Practitioners Certification ProgramAmerican Academy of NursingAmerican Association of Critical Care NursesAmerican Association of Critical Care Nurses Certification ProgramAmerican Association of Nurse AnesthetistsAmerican Association of Occupational Health NursesAmerican Board of Nursing SpecialtiesAmerican College of Nurse PractitionersAmerican College of Nurse-MidwivesAmerican Nurses AssociationAmerican Nurses Credentialing CenterAmerican Organization of Nurse ExecutivesAmerican Psychiatric Nurses AssociationAssociation of Faculties of Pediatric Nurse PractitionersAssociation of Rehabilitation NursesAssociation of Women’s Health, Obstetric and Neonatal NursesCertification Board Perioperative NursingCommission on Collegiate Nursing EducationCouncil on Accreditation of Nurse Anesthesia Educational ProgramsDivision of Nursing, DHHS, HRSAEmergency Nurses AssociationHospice and Palliative Nurses AssociationInternational Nurses Society on AddictionsInternational Society of Psychiatric-Mental Health Nurses NANDA InternationalNational Association of Clinical Nurse SpecialistsNational Association of Neonatal NursesNational Association of Nurse Practitioners in Women’s HealthNational Association of Nurse Practitioners in Women’s Health, Council on AccreditationNational Association of Pediatric Nurse PractitionersNational Association of School NursesNational Board for Certification of Hospice and Palliative NursesNational Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing SpecialtiesNational Conference of Gerontological Nurse PractitionersNational Council of State Boards of NursingNational Gerontological Nursing AssociationNational League for NursingNational League for Nursing Accrediting CommissionNational Organization of Nurse Practitioner FacultiesP.81Nurse Licensure Compact Administrators/State of Utah Department of Commerce/Division of Occupational & Professional LicensingNurses Organization of Veterans AffairsOncology Nursing Certification CorporationOncology Nursing SocietyPediatric Nursing Certification BoardSigma Theta Tau, InternationalSociety of Pediatric NursesWound Ostomy & Continence Nurses SocietyWound Ostomy Continence Nursing Certification BoardP.82APPENDIX GORGANIZATIONS PARTICIPATING IN APRN CONSENSUS PROCESSAcademy of Medical-Surgical NursesAccreditation Commission for Midwifery EducationAmerican College of Nurse-midwives Division of AccreditationAmerican Academy of Nurse PractitionersAmerican Academy of Nurse Practitioners Certification ProgramAmerican Association of Colleges of NursingAmerican Association of Critical Care Nurses CertificationAmerican Association of Neuroscience NursesAmerican Association of Nurse AnesthetistsAmerican Association of Occupational Health NursesAmerican Board for Occupational Health NursesAmerican Board of Nursing SpecialtiesAmerican College of Nurse-MidwivesAmerican College of Nurse PractitionersAmerican Holistic Nurses AssociationAmerican Nephrology Nurses AssociationAmerican Nurses AssociationAmerican Nurses Credentialing CenterAmerican Organization of Nurse ExecutivesAmerican Psychiatric Nurses AssociationAmerican Society of PeriAnesthesia NursesAmerican Society for Pain Management NursingAssociation of Community Health Nursing EducatorsAssociation of Faculties of Pediatric Nurse PractitionersAssociation of Nurses in AIDS CareAssociation of PeriOperative Registered NursesAssociation of Rehabilitation NursesAssociation of State and Territorial Directors of nursingAssociation of Women’s Health, Obstetric and Neonatal NursesBoard of Certification for Emergency NursingCouncil on Accreditation of Nurse Anesthesia Educational ProgramsCommission on Collegiate Nursing EducationCommission on Graduates of Foreign Nursing SchoolsDistrict of Columbia Board of NursingDepartment of HealthDermatology Nurses AssociationDivision of Nursing, DHHS, HRSAEmergency Nurses AssociationGeorge Washington UniversityHealth Resources and Services AdministrationInfusion Nurses SocietyInternational Nurses Society on AddictionsInternational Society of Psychiatric-Mental Health NursesKentucky Board of NursingP.83National Association of Clinical Nurse SpecialistsNational Association of Neonatal NursesNational Association of Nurse Practitioners in Women’s Health, Council on AccreditationNational Association of Pediatric Nurse PractitionersNational Association of School of NursesNational Association of Orthopedic NursesNational Certification Corporation for the Obstetric, Gynecologic, and Neonatal Nursing SpecialtiesNational Conference of Gerontological Nurse PractitionersNational Council of State Boards of NursingNational League for NursingNational League for Nursing Accrediting CommissionNational Organization of Nurse Practitioner FacultiesNephrology Nursing Certification CommissionNorth American Nursing Diagnosis Association InternationalNurses Organization of Veterans AffairsOncology Nursing Certification CorporationOncology Nursing SocietyPediatric Nursing Certification BoardPennsylvania State Board of NursingPublic Health Nursing Section of the American Public Health Association.Rehabilitation Nursing Certification BoardSociety for Vascular NursingTexas Nurses AssociationTexas State Board of NursingUtah State Board of NursingWomen’s Health, Obstetric & Neonatal NursesWound, Ostomy, & Continence Nurses SocietyWound, Ostomy, & Continence Nursing CertificationP.84APPENDIX HAPRN CONSENSUS PROCESS WORK GROUPORGANIZATIONS THAT WERE REPRESENTED AT THE WORK GROUP MEETINGSJan Towers, American Academy of Nurse Practitioners Certification ProgramJoan Stanley, American Association of Colleges of NursingCarol Hartigan, American Association of Critical Care Nurses Certification CorporationLeo LeBel, American Association of Nurse AnesthetistsBonnie Niebuhr, American Board of Nursing SpecialtiesPeter Johnson & Elaine Germano, American College of Nurse-MidwivesMary Jean Schumann, American Nurses AssociationMary Smolenski, American Nurses Credentialing CenterM.T. Meadows, American Organization of Nurse ExecutivesEdna Hamera & Sandra Talley, American Psychiatric Nurses AssociationElizabeth Hawkins-Walsh, Association of Faculties of Pediatric Nurse PractitionersJennifer Butlin, Commission on Collegiate Nursing EducationLaura Poe, APRN Compact AdministratorsBetty Horton, Council on Accreditation of Nurse Anesthesia Educational ProgramsKelly Goudreau, National Association of Clinical Nurse SpecialistsFran Way, National Association of Nurse Practitioners in Women’s Health, Council on AccreditationMimi Bennett, National Certification Corporation for the Obstetric, Gynecologic, and Neonatal Nursing SpecialtiesKathy Apple, National Council of State Boards of NursingGrace Newsome & Sharon Tanner, National League for Nursing Accrediting CommissionKitty Werner & Ann O’Sullivan, National Organization of Nurse Practitioner FacultiesCyndi Miller-Murphy, Oncology Nursing Certification CorporationJanet Wyatt, Pediatric Nursing Certification BoardCarol Calianno, Wound, Ostomy and Continence Nursing Certification BoardIrene Sandvold, DHHS, HRSA, Division of Nursing (observer)P.85ADDENDUMExample of a National Consensus-Building Process to Develop Nationally Recognized Education Standards and Role/Specialty CompetenciesThe national consensus-based process described here was originally designed, with funding by the Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing, to develop and validate national consensus-based primary care nurse practitioner competencies in five specialty areas. The process was developed with consultation from a nationally recognized expert in higher education assessment. The process subsequently has been used and validated for the development of similar sets of competencies for other areas of nursing practice, including competencies for mass casualty education for all nurses and competencies for acute care nurse practitioners and psych/mental health nurse practitioners.This process for developing nationally recognized educational standards, nationally recognized role competencies and nationally recognized specialty competencies is an iterative, step-wise process. The steps are:Step 1: At the request of the organization(s) representing the role or specialty, a neutral group or groups convenes and facilitates a national panel of all stakeholder organizations as defined in step 2.Step 2: To ensure broad representation, invitations to participate should be extended to one representative of each of the recognized nursing accrediting organizations, certifiers within the role and specialty, groups whose primary mission is graduate education and who have established educational criteria for the identified role and specialty, and groups with competencies and standards for education programs that prepare individuals in the role and specialty.Step 3: Organizational representatives serving on the national consensus panel bring and share role delineation studies, competencies for practice and education, scopes and standards of practice, and standards for education programs.Step 4: Agreement is reached among the panel membersStep 5: Panel members take the draft to their individual boards for feedback.Step 6: That feedback is returned to the panel. This is an iterative process until agreement is reached.Step 7: Validation is sought from a larger group of stakeholders including organizations and individuals. This is known as the Validation Panel.Step 8: Feedback from the Validation Panel is returned to National Panel to prepare the final document.Step 9: Final document is sent to boards represented on the National Panel and the Validation Panel for endorsement.The final document demonstrates national consensus through consideration of broad input from key stakeholders. The document is then widely disseminated.Appendix B.Nursing’s Social Policy Statement, 2nd Edition (2003)The content in this appendix is not current and is of historical significance only.P.88INTRODUCTION“Nursing is the pivotal health care profession, highly valued for its specialized knowledge, skill and caring in improving the health status of the public and ensuring safe, effective, quality care. The profession mirrors the diverse population it serves and provides leadership to create positive changes in health policy and delivery systems. Individuals choose nursing as a career, and remain in the profession, because of the opportunities for personal and professional growth, supportive work environments and compensation commensurate with roles and responsibilities.1The Social Context of NursingNursing’s Social Policy Statement, Second Edition expresses the social contract between society and the profession of nursing. Registered nurses and others can use this document as a framework for understanding professional nursing’s relationship with society and its obligation to those who receive professional nursing care. It includes a definition of professional nursing, descriptions of professional nursing and its knowledge base, and brief descriptions of the scope of professional nursing practice and the methods by which the profession is regulated. These concepts underlie the practice of professional nursing, provide direction for clinicians, educators, administrators, and scientists within professional nursing, and inform other healthcare professionals, public policymakers, and funding bodies about professional nursing’s contribution to health care.This statement is derived from the 1980 landmark document, Nursing: A Social Policy Statement,2 and Nursing’s Social Policy Statement,3 published in 1995. These documents provided the profession’s earlier descriptions of its social responsibility and professional nursing’s roles in the American healthcare system. The current document presents the practice of professional nursing as it has evolved, and provides direction for the future.Professional nursing, like other professions, is an essential part of the society from which it grew and within which it continues to evolve. Professional nursing is dynamic, rather than static, reflecting the changing nature of societal needs. Professional nursing can be said to be owned by society, in the sense that “a profession acquires recognition, relevance, and P.89even meaning in terms of its relationship to that society, its culture and institutions, and its other members.”4 This social contract between the broader society and its professions has been expressed as follows:Societies (and often vested interests within them)… determine, in accord with their different technological and economic levels of development and their socioeconomic, political and cultural conditions and values, what professional skills and knowledge they most need or desire… Logically, then, the professions open to individuals in any particular society are the property not of the individual but of the society. What individuals acquire through training is professional knowledge and skill, not a profession or even part ownership of one.5The authority for the practice of professional nursing is based on a social contract that acknowledges professional rights and responsibilities as well as mechanisms for public accountability.Society grants the professions authority over functions vital to itself and permits them considerable autonomy in the conduct of their affairs. In return, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality in performance is at the heart of this relationship. It is the authentic hallmark of a mature profession.6To maximize the contributions nurses make to society, it is necessary to protect the dignity and autonomy of nurses in the workplace. To that end, the American Nurses Association has adopted the Bill of Rights for Registered Nurses.7P.90Values and Assumptions of Nursing’s Social ContractThe following values and assumptions undergird professional nursing’s contract with society:Humans manifest an essential unity of mind, body, and spirit.Human experience is contextually and culturally defined.Health and illness are human experiences. The presence of illness does not preclude health nor does optimal health preclude illness.The relationship between nurse and patient involves participation of both in the process of care.The interaction between nurse and patient occurs within the context of the values and beliefs of the patient and the nurse.Public policy and the healthcare delivery system influence the health and well-being of society and professional nursing.These values and assumptions apply whether the recipient of professional nursing care is an individual, family, group, community, or population.P.91DEFINITION OF NURSINGDefinitions of nursing have evolved to acknowledge six essential features of professional nursing:provision of a caring relationship that facilitates health and healing,attention to the range of human experiences and responses to health and illness within the physical and social environments,integration of objective data with knowledge gained from an appreciation of the patient or group’s subjective experience,application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking,advancement of professional nursing knowledge through scholarly inquiry, andinfluence on social and public policy to promote social justice.In her Notes on Nursing: What It Is and What It Is Not, published in 1859, Florence Nightingale defined nursing as having “charge of the personal health of somebody…and what nursing has to do…is to put the patient in the best condition for nature to act upon him.”8A century later, Virginia Henderson defined the purpose of nursing as “to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.”9In the 1980 Nursing: A Social Policy Statement, nursing was defined as “the diagnosis and treatment of human responses to actual or potential health problems.”10P.92A broader definition is consistent with professional nursing’s commitment to meeting societal needs, and permits the profession and its practitioners to adapt to the ongoing changes in healthcare environments, practice expectations, and the profession itself. The evolution of nursing practice leads to the following definition of professional nursing:Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.11Moreover, nursing addresses the organizational, social, economic, legal, and political factors within the healthcare system and society. These and other factors affect the cost, access to, and quality of health care and the vitality of the nursing profession. This is accomplished through a variety of means.P.93KNOWLEDGE BASE FOR NURSING PRACTICENursing is a profession and a scientific discipline. The knowledge base for professional nursing practice includes nursing science, philosophy, and ethics, as well as physical, economic, biomedical, behavioral, and social sciences. To refine and expand the knowledge base and science of the discipline, nurses generate and use theories and research findings that are selected on the basis of their fit with professional nursing’s values of health and health care, as well as their relevance to professional nursing practice.Nurses are concerned with human experiences and responses across the lifespan. Nurses partner with individuals, families, communities, and populations to address issues such as:promotion of health and safety;care and self-care processes;physical, emotional, and spiritual comfort, discomfort, and pain;adaptation to physiologic and pathophysiologic processes;emotions related to experiences of birth, growth and development, health, illness, disease, and death;meanings ascribed to health and illness;decision-making and ability to make choices;relationships, role performance, and change processes within relationships;social policies and their effects on the health of individuals, families, and communities;healthcare systems and their relationships with access to and quality of health care; andthe environment and the prevention of disease.Nurses use their theoretical and evidence-based knowledge of these phenomena in collaborating with patients to assess, plan, implement, and evaluate care. Nursing interventions are intended to produce beneficial effects and contribute to quality outcomes. Nurses evaluate the effectiveness of their care in relation to identified outcomes and use evidence to improve care.P.94Scope of Nursing PracticeProfessional nursing has one scope of practice, which encompasses the range of activities from those of the beginning registered nurse through the advanced level. While a single scope of professional nursing practice exists, the depth and breadth to which individual nurses engage in the total scope of professional nursing practice is dependent on their educational preparation, their experience, their role, and the nature of the patient population they serve.Further, all nurses are responsible for practicing in accordance with recognized standards of professional nursing practice and professional performance. The level of application of standards varies with the education, experience, and skills of the individual nurse. Since 1965, ANA has consistently affirmed the baccalaureate degree in nursing as the preferred educational requirement for entry into professional nursing practice.12 Each nurse remains accountable for the quality of care within his or her scope of nursing practice.Professional nursing’s scope of practice is dynamic and continually evolving. It has a flexible boundary that is responsive to the changing needs of society and the expanding knowledge base of its theoretical and scientific domains. This scope of practice thus overlaps those of other professions involved in health care. The boundaries of each profession are constantly changing, and members of various professions cooperate by sharing knowledge, techniques, and ideas about how to deliver quality health care. Collaboration among healthcare professionals involves recognition of the expertise of others within and outside the profession, and referral to those other providers when appropriate. Collaboration also involves some shared functions and a common focus on the same overall mission.Nurses provide care for patients in a variety of settings. Nurses may initiate treatments or carry out interventions initiated by other authorized healthcare providers. Nurses are coordinators of care as well as caregivers.Nursing practice includes, but is not limited to, initiating and maintaining comfort measures, promoting and supporting human functions and responses, establishing an environment conducive to well-being, providing health counseling and teaching, and collaborating on certain aspects of the health regimen. This practice is based on understanding the human condition across the life span and the relationship of the individual within the environment.P.95Nursing care is provided and directed by registered nurses and advanced practice registered nurses. All registered nurses are educated in the art and science of nursing with the goal of helping patients to attain, maintain, and restore health, or to experience a dignified death. Registered nurses and advanced practice registered nurses may also develop expertise in a particular specialty.Specialization in NursingSpecialization involves focusing on a part of the whole field of professional nursing. The American Nurses Association and specialty nursing organizations delineate the components of professional nursing practice that are essential for any particular specialty. Registered nurses may seek certification in a variety of specialized areas of nursing practice.Advanced Practice Registered NursesAdvanced practice registered nurses (that is, nurse practitioners, certified registered nurse anesthetists, certified nurse-midwives, and clinical nurse specialists) practice from both expanded and specialized knowledge and skills.Expansion refers to the acquisition of new practice knowledge and skills, including the knowledge and skills that authorize role autonomy within areas of practice that may overlap traditional boundaries of medical practice.Specialization is concentrating or delimiting one’s focus to part of the whole field of professional nursing (such as ambulatory care, pediatric, maternal-child, psychiatric, palliative care, or oncology nursing).Advanced practice is characterized by the integration and application of a broad range of theoretical and evidence-based knowledge that occurs as a part of graduate nursing education. Advanced practice registered nurses hold master’s or doctoral degrees and are licensed, certified, and/or approved to practice in their roles.P.96Additional Advanced RolesContinuation of the profession of nursing is also dependent on the education of nurses, appropriate organization of nursing services, continued expansion of nursing knowledge, and the development and adoption of policies consistent with values and assumptions that underlie the scope of professional nursing practice. Registered nurses may practice in such advanced roles as nurse educator, nurse administrator, nurse researcher, and nurse policy analyst. These advanced roles require specific additional knowledge and skills at the graduate level. Generally, those practicing in these roles hold master’s or doctoral degrees.Further details on the scope of professional nursing practice, specifics describing the who, what, where, when, why, and how of both specialized and advanced areas of nursing practice, are found in the current version of Nursing: Scope and Standards of Practice.13P.97THE REGULATION OF NURSING PRACTICEProfessional nursing, like other professions, is accountable for ensuring that its members act in the public interest in the course of providing the unique service society has entrusted to them. The processes by which the profession does this include self-regulation, professional regulation, and legal regulation.Self-RegulationSelf-regulation involves personal accountability for the knowledge base for professional practice. Nurses develop and maintain current knowledge, skills, and abilities through formal and continuing education. Where appropriate, nurses hold certification in their area of practice to demonstrate this accountability.Nurses also regulate themselves as individuals through peer review of their practice. Continuous performance improvement fosters the refinement of knowledge, skills, and clinical decision-making processes at all levels and in all areas of professional nursing practice. As expressed in the profession’s code of ethics, peer review is one mechanism by which nurses are held accountable for practiceAs noted in Provision 3.4 (Standards and Review Mechanisms) of Code of Ethics for Nurses with Interpretive Statements,14 nurses should also be active participants in the development of policies and review mechanisms designed to promote patient safety, reduce the likelihood of errors, and address both environmental system factors and human factors that present increased risk to patients. In addition, when errors do occur, nurses are expected to follow established guidelines in reporting errors committed or observed.P.98Professional RegulationProfessional nursing defines its practice base, provides for research and development of that practice base, establishes a system for nursing education, establishes the structures through which nursing services will be delivered, and provides quality review mechanisms such as a code of ethics, standards of practice, structures for peer review, and a system of credentialing.Professional regulation of nursing practice begins with the profession’s definition of nursing and the scope of professional nursing practice. Professional standards are then derived from the scope of professional nursing practice.Certification is a judgment of competence made by nurses who are themselves practicing within the area of specialization. Several credentialing boards are associated with the American Nurses Association and with specialty nursing organizations. These boards develop and implement certification examinations and procedures for nurses who wish to have their specialty practice knowledge recognized by the profession and the public. One component of the required evidence is successful completion of an examination that tests the knowledge base for the selected area of practice. Other requirements relate to the content of coursework and amount of supervised practice.P.99Legal RegulationAll nurses are legally accountable for actions taken in the course of professional nursing practice as well as for actions assigned by the nurse to others assisting in the provision of nursing care. Such accountability is accomplished through the legal regulatory mechanisms of licensure and criminal and civil laws.The legal contract between society and the professions is defined by statute and by associated rules and regulations. State nurse practice acts and related legislative and regulatory initiatives serve as the explicit codification of the profession’s obligation to act in the best interests of society. Nurse practice acts grant nurses the authority to practice and grant society the authority to sanction nurses who violate the norms of the profession or act in a manner that threatens the safety of the public.Statutory definitions of nursing should be compatible with and build upon the profession’s definition of its practice base, but be general enough to provide for the dynamic nature of an evolving scope of nursing practice. Society is best served when consistent definitions of the scope of nursing practice are used by states. This allows residents of all states to access the full range of nursing services.P.100CONCLUSIONNursing’s Social Policy Statement, Second Edition describes professional nursing in the United States of America. It includes an identification of the values and the social responsibility of the profession, a definition of professional nursing, a brief discussion of the scope of practice, and a description of professional nursing’s knowledge base and the methods by which professional nursing is regulated. Nursing’s Social Policy Statement, Second Edition provides both an accounting of nursing’s professional stewardship and an expression of professional nursing’s continuing commitment to the society it serves.P.101REFERENCES1. Nursing’s Agenda for the Future Steering Committee. Nursing’s Agenda for the Future (Washington, D.C.: American Nurses Publishing, 2001). Also available on the ANA web site: http://www.nursingworld.org/naf/2. American Nurses Association. Nursing: A Social Policy Statement (Kansas City, MO. American Nurses Association, 1980).3. American Nurses Association. Nursing’s Social Policy Statement (Washington, D.C.: American Nurses Publishing, 1995).4. Page, B.B. “Who owns the profession?,” Hastings Center Report 5(5): 7-8 (1975).5. Ibid., 7.6. Donabedian, A. Foreword in M. Phaneuf, The Nursing Audit: Self-Regulation in Nursing Practice, 2nd ed. (New York: Appleton-Century-Crofts, 1972), 8.7. American Nurses Association. Bill of Rights for Registered Nurses (Washington, D.C.: American Nurses Publishing, 2001), 1.8. Nightingale, F. Notes on Nursing: What It Is and What It Is Not. (1859; reprint, New York: J. B. Lippincott Company, 1946), preface, 75.9. Henderson, V. Basic Principles of Nursing Care (London: International Council of Nurses, 1961), 42.10. American Nurses Association, Nursing: A Social Policy Statement. (Kansas City, MO. American Nurses Association, 1980).11. Adapted from: American Nurses Association. Code of Ethics for Nurses with Interpretive Statements (Washington, D.C.: American Nurses Publishing, 2001), 5. (Also on the ANA web site: http://nursingworld.org/ethics/ecode.htm)12. American Nurses Association House of Delegates. Titling for Licensure (Kansas City, MO: American Nurses Association, 1985).13. American Nurses Association. Nursing: Scope and Standards of Practice (Washington, D.C.: American Nurses Publishing, 2003).14. American Nurses Association, Code of Ethics for Nurses with Interpretive Statements, 13-14.15. Ibid., 24.P.102APPENDIX ATHE DEVELOPMENT OF NURSING’S SOCIAL POLICY STATEMENTS, 1980-2003Contributors, 1980-2003Nursing’s Social Policy Statement Revision Task Force, 2001-2003Naomi E. Ervin, RN, PhD, APRN, BC, FAAN; Chair (2002-2003)Anne M. McNamara, PhD, RN; Chair (2001-2002)Linda A. Beechinor, MS, RN, FNPJoan M. Caley, RN, MS, CNAA, CSMary B. Killeen, PhD, RN, C, CNAALinda L. Olson, PhD, RN, CNAASusan Foley Pierce, PhD, RNSteven R. Pitkin, RN, MNBetty Smith-Campbell, PhD, RN, ARNPSusan Tullai-McGuinness, PhD, MPA, RNMarva Wade, RNSocial Policy Statement Task Force, 1992-1995Linda R. Cronenwett, PhD, RN, FAAN; Facilitator (1994-1995)Barbara E. Pokorny, MSN, RN, CS; Facilitator (1992-1993)Kathryn Barnard, PhD, RN, FAANSusan E. Doughty, MSN, RN, CSBeverly Hall, PhD, RN, FAANGail A. Harkness, DrPH, RN, FAANMary S. Koithan, PhD, RNFrank R. Lamendola, MSN, RN, CSMary K. Walker, PhD, RN, FAANNursing: A Social Policy Statement, Authors, 1980Norma Lang, PhD, RN, FAAN; ChairNina T. Argondizzo, MA, RNKathryn Barnard, PhD, RN, FAANHildegard E. Peplau, EdD, RN, FAANMaria C. Phaneuf, MA, RN, FAANJean E. Steel, PhD, RN, FAANGlenn Webster, PhDP.103Congress on Nursing Practice and Economics 2002-2004Anne M. Hammes, MS, RN, CNAA; ChairMarva Wade, RN, Vice ChairKathryn Ballou, PhD, RNJoan M. Caley, MS, RN, CS, CNAANaomi E. Ervin, RN, PhD, APRN, BC, FAANTracy A. Hollar-Ruegg, MS, RN, CNPSaul Josman, MN, RN, APRN-BCDavid Marshall, JD, RN, CNAAMary A. Maryland, PhD, APRN,BC , APNMaureen Ann Nalle, PhD, RNSusan Foley Pierce, PhD, RNSteven R. Pitkin, RN, MNLorna Samuels, BSN, RN, BCCathalene Teahan, MSN, RN, CNSSusan Tullai-McGuinness, PhD, MPA, RNCongress on Nursing Practice and Economics 2000-2002Linda J. Gobis, JD, RN, FNP; ChairAnne M. McNamara, PhD, RN, Vice ChairLinda A. Beechinor, MS, RN, FNPSharon Bidwell-Cerone, PhD, RN, CS-PNPJoan M. Caley, RN, MS, CNAA, CSMary Chaffee, MS, RN, CNA, CCRNNaomi E. Ervin, PhD, RN, CS, FAANAnne M. Hammes, MS, RN, CNAASaul Josman, MN, RN, APRN-BCMary B. Killeen, PhD, RN, C, CNAAPatricia (Patti) J. Kummeth, MSN, RN, CDavid Marshall, JD RN, BSNLinda L. Olson, PhD, RN, CNAASteven R. Pitkin, RN, MNLorna Samuels, BSN, RN, CMarva Wade, RNAppendix C.Nursing’s Social Policy Statement (1995)The content in this appendix is not current and is of historical significance only.CONTENTSPREFACEviiINTRODUCTION1The Social Context of Nursing2Values and Assumptions3DEFINITION OF NURSING5KNOWLEDGE BASE FOR NURSING PRACTICE7SCOPE OF NURSING PRACTICE11Basic Nursing Practice13Advanced Nursing Practice14REGULATION OF NURSING PRACTICE17Professional Regulation17Legal Regulation19Self-Regulation19CONCLUSION21REFERENCES22P.106P.107PREFACENursing’s Social Policy Statement, a reality after several years work by hundreds of nurses, represents nursing’s commitment to the society and people we serve.Nine nurses served on the task force that led a professionwide effort to create this statement. We are indebted to the task force members, the authors of the landmark 1980 Nursing: A Social Policy Statement, and to the nurses in ANA organizational units, state nurses associations (SNAs), and nursing organizations throughout the country P.108who passionately debated the contents and suggested changes after reviewing two drafts of the document.The task force has responded to widespread suggestions that the statement be both clear and brief. Two areas of compromise contributed to brevity but not always to precision. First, the recipients of nursing care are individuals, groups, families, or communities. This point is made frequently throughout the statement but not in every possible paragraph. We ask readers to keep in mind that nursing practice in its entirety always includes these various recipients of care.Second, the individual recipient of nursing care can be referred to as patient, client, or person. Instead of using all terms or varying terms throughout the document, we chose to refer to individual recipients of care as patients.We acknowledge the fact that the term client is preferred by some nurses because it implies a more egalitarian relationship than the term patient. The term client, however, implies that a choice can be made by the recipient of care about which professional, among many, will provide the desired services. At this point in our history, the bulk of nursing practice does not include that type of choice on the part of the recipient of care. The term patient, therefore, is used throughout the statement to provide consistency and brevity, bearing in mind that the terms client or individual, in some instances, might be better choices.The term patient, therefore, is used throughout the statement to provide consistency and brevity, bearing in mind that the terms client or individual, in some instances, might be better choices.The members of the 1992-1994 and 1994-1996 Congresses of Nursing Practice contributed significantly to the development of Nursing’s Social Policy Statement. Some helped create the direction and processes for the work, some served on the task force, and all brought insight, commitment, and thoughtful creativity to the P.109consensus-building process. We are grateful for the invaluable support that Dr. Patricia Rowell, Senior Policy Fellow, ANA Department of Practice, Economics, and Policy, provided during public debate on the statement.Nursing’s Social Policy Statement now belongs to the profession. Future congresses of nursing practice will monitor the use of this 1995 statement, aware that the profession, health care, and society are constantly evolving.Mary K. Walker, Ph.D., R.N., F.A.A.N. Chair, Congress of Nursing Practice 1994-1996Linda R. Cronenwett, Ph.D., R.N., F.A.A.N. Chair, Congress of Nursing Practice 1990-1994P.110INTRODUCTIONNursing’s Social Policy Statement is a document that nurses can use as a framework for understanding nursing’s relationship with society and nursing’s obligation to those who receive nursing care.The statement includes descriptions of nursing and its knowledge base, the scope of nursing practice, and the methods by which the profession is regulated. The conceptualization of the clinical practice of nursing that is the focus of this statement will provide direction for clinicians, P.111educators, administrators, and scientists within the profession of nursing and inform other health care professionals, public policy makers, and funding entities about nursing’s contribution to health care.This statement is derived from the landmark document, Nursing: A Social Policy Statement (1980),1 the profession’s first description of its social responsibility and nursing’s roles in the American health care system. The current document presents clinical nursing practice as it has evolved according to society’s health needs and sets direction for the future.The Social Context of NursingNursing, like other professions, is an essential part of the society from which it has grown and within which it continues to evolve. Nursing is dynamic, rather than static, and reflects the changing nature of societal need. Nursing can be said to be “owned by society” in the sense that “a profession acquires recognition, relevance, and even meaning in terms of its relationship to that society, its culture and institutions, and its other members.”2This social contract between the broader society and its professions has been expressed as follows:“Professions acquire recognition and relevance primarily in terms of needs, conditions, and traditions of particular societies and their members … societies (and often vested interests within them) … determine, in accord with their different technological and economic levels of development and their socioeconomic, political, and cultural conditions and values, what professional skills and knowledge they most need and desire… .P.112“Logically, then, the professions open to individuals in any particular society are the property not of the individual but of society. What individuals acquire through training is professional knowledge and skill, not a profession or even part ownership of one.”2The authority for the practice of nursing is based on a social contract that acknowledges professional rights and responsibilities as well as mechanisms for public accountability.The authority for the practice of nursing is based on a social contract that acknowledges professional rights and responsibilities as well as mechanisms for public accountability.“Society grants the professions authority over functions vital to itself and permits them considerable autonomy in the conduct of their affairs. In return, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality in performance is at the heart of this relationship. It is the authentic hallmark of a mature profession.”3People seek the services of nurses to obtain information and treatment in matters of health and illness. They use nursing care to resolve problems or manage health-promoting behaviors. Nurses help people identify both short- and long-term health goals and act as advocates for people dealing with barriers encountered in obtaining health care.4Values and AssumptionsSome values and assumptions that undergird Nursing’s Social Policy Statement are:[black four-pointed star] Humans manifest an essential unity of mind/body/spirit.[black four-pointed star] Human experience is contextually and culturally defined.P.113[black four-pointed star] Health and illness are human experiences.[black four-pointed star] The presence of illness does not preclude health nor does optimal health preclude illness.Furthermore, the relationship between a nurse and patient involves full and active participation of the patient and the nurse in the plan of care and occurs within the context of the values and beliefs of the patient and the nurse. The same values and assumptions apply when the recipient of nursing is a family or community.P.114DEFINITION OF NURSINGNursing was defined in Florence Nightingale’s Notes on Nursing: What It Is and What It Is Not, published in 1859, as having “charge of the personal health of somebody … and what nursing has to do … is to put the patient in the best condition for nature to act upon him.”5A century later, Virginia Henderson defined the purpose of nursing as “to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or P.115knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.”6 In the 1980 Nursing: A Social Policy Statement, nursing was defined as “the diagnosis and treatment of human responses to actual or potential health problems.”1These definitions illustrate the consistent orientation of nurses to the provision of care that promotes well-being in the people served.These definitions illustrate the consistent orientation of nurses to the provision of care that promotes well-being in the people served. The nursing profession remains committed to the care and nurturing of both healthy and ill people, individually or in groups and communities.Since 1980, nursing philosophy and practice have been influenced by a greater elaboration of the science of caring and its integration with the traditional knowledge base for diagnosis and treatment of human responses to health and illness. As such, definitions of nursing more frequently acknowledge four essential features of contemporary nursing practice:[black four-pointed star] attention to the full range of human experiences and responses to health and illness without restriction to a problem-focused orientation;[black four-pointed star] integration of objective data with knowledge gained from an understanding of the patient or group’s subjective experience;[black four-pointed star] application of scientific knowledge to the processes of diagnosis and treatment; and,[black four-pointed star] provision of a caring relationship that facilitates health and healing.P.116KNOWLEDGE BASE FOR NURSING PRACTICENursing is a scientific discipline as well as a profession.The knowledge base for nursing practice is derived from multiple sources, including nursing science, philosophy, and ethics, and physical, economic, biomedical, behavioral, and social sciences. To expand the knowledge base of the discipline, nurses generate and utilize theories and research findings that are relevant to nursing practice and fit with nursing’s values about health and illness.P.117Phenomena of ConcernThe phenomena of concern to nurses are human experiences and responses to birth, health, illness, and death. Nurses focus on these phenomena within the context of individuals, families, groups, and communities.Following are examples of phenomena that are foci of nursing care and research:[black four-pointed star] care and self-care processes;[black four-pointed star] physiological and pathophysiological processes—such as rest, sleep, respiration, circulation, reproduction, nutrition, elimination, sexuality, and communication;[black four-pointed star] physical and emotional comfort, discomfort, and pain;[black four-pointed star] emotions related to experiences of birth, health, illness, and death;[black four-pointed star] meanings ascribed to health and illness;[black four-pointed star] decision- and choice-making abilities;[black four-pointed star] perceptual orientations such as self-image and control over one’s body and environments;[black four-pointed star] relationships, role performance, and change processes within relationships; and,[black four-pointed star] social policies and their effects on the health of individuals, families, and communities.The nurse’s theoretical and research-based understandings of these phenomena and the preferences of patients, families, or communities guide the formulation of plans of care.P.118Interventions are recommended based on the nurse’s clinical judgment about the phenomena of concern and theoretical, practical, or scientific knowledge about the relationships between potential interventions and desired outcomes.DiagnosisNurses identify the human responses to actual or potential health problems they observe and name their conceptualization of the diagnosis using a variety of classification systems.7 Diagnoses facilitate communication among health care providers and the recipients of care and provide for initial direction in choice of treatments and subsequent evaluation of the outcomes of care.InterventionsThe actions nurses take on behalf of patients, families, or communities are referred to as nursing interventions or treatments. The aim of nursing actions is to assist patients, families, and communities to improve, correct, or adjust to physical, emotional, psychosocial, spiritual, cultural, and environmental conditions for which they seek help.Nursing interventions may be either direct or indirect. Direct care interventions are performed through interaction with patients. Indirect care interventions are performed away from the patient but on behalf of a patient or group of patients, and are aimed at management of the care environment and interdisciplinary collaboration.8 Interventions are recommended based on the nurse’s clinical judgment about the phenomena of concern and theoretical, practical, or scientific knowledge about the relationships between potential interventions and desired outcomes.When nursing care is provided to individuals, it is provided within relationships that involve both physical and emotional intimacy. Nursing assessments, treatments, and comfort care are delivered with compassion and respect for human dignity. The interpersonal closeness P.119that develops between a nurse and patient provides a context for open discussion of the patient’s experiences of health and illness. The nature of the relationship, therefore, allows the nurse to assist people effectively, whether giving physical care, providing emotional support, engaging in health teaching or counseling, or assisting recovery or a peaceful death.OutcomesNursing interventions are intended to produce beneficial effects for the patient, family, or community. Nurses evaluate the effectiveness of their interventions in relation to identified outcomes and use these assessments to revise diagnoses, outcomes, and plans of care. Whenever possible, recipients of care participate in determining whether nursing actions have been effective.P.120SCOPE OF NURSING PRACTICENursing involves practices that are restorative, supportive, and promotive in nature.4Restorative practices modify the impact of illness or disease. Supportive practices are oriented toward modification of relationships or the environment to support health. Promotive practices mobilize healthy patterns of living, foster personal and family development, and support selfdefined goals of individuals, families, and communities.Nursing’s scope of practice is dynamic and evolves with changes in the phenomena of P.121concern, in knowledge about various interventions’ effects on patient or group outcomes, or in the political environment, legal conditions, and cultural and demographic patterns in society. The extent to which individual nurses engage in the total scope of nursing practice is dependent on their educational preparation, experience, roles, and the nature of the patient populations they serve.The extent to which individual nurses engage in the total scope of nursing practice is dependent on their educational preparation, experience, roles, and the nature of the patient populations they serve.ANA and specialty nursing organizations often delineate scopes of practice for nurses who have chosen to focus their practices in a particular specialty. Differences among nurses in their scopes of practice can be characterized as intraprofessional intersections across which collegial, collaborative practice occurs.Nursing is not separated from other professions by rigid boundaries. Nursing’s scope of practice has a flexible boundary that is responsive to the changing needs of society and the expanding knowledge base of its theoretical and scientific domains.The boundaries of each health care profession are constantly changing, and members of various professions cooperate by exchanging knowledge and ideas about how to deliver high quality health care. Collaboration among health care professionals involves recognition of the expertise of others within and outside one’s profession and referral to those providers when appropriate. Collaboration also involves some shared functions and a common focus on the same overall mission.Nursing care is provided by nurses in both basic and advanced practice. Within each type of practice, individual nurses demonstrate competence along a continuum from novice to expert.9 In addition, within each type of practice, nurses can choose to develop expertise in a particular specialty.P.122Basic Nursing PracticeNurses who practice at the basic or entry level of practice have graduated from approved schools of nursing and have qualified by national examination for registered nurse (R.N.) licenses. Since 1965, ANA has consistently affirmed the baccalaureate degree in nursing as the preferred educational requirement for basic nursing practice.Beyond formal education, nurses in basic practice can choose to focus their experience and continuing education on an area of specialty in nursing, and this specialized knowledge base may be acknowledged through certification. As the basis for granting certification, many credentialing bodies require the baccalaureate degree in nursing in addition to other demonstrations of knowledge in specialty practice. Although practices of individual nurses vary according to level of education, experience, competence, and role, all nurses are accountable for meeting the profession’s standards of clinical practice.10Nurses practicing at the basic level provide care for patients and families in environments such as homes, schools, and places of employment, as well as in hospitals, ambulatory care settings, skilled nursing facilities, long-term care institutions, protective or custodial institutions, and nurse-managed and other community-based health centers.Based on outcomes desired, nurses intervene to promote health, prevent illness, or assist with activities that contribute to recovery from illness or to achieving a peaceful death. They may initiate treatments themselves or carry out interventions initiated by advanced practice registered nurses or other licensed health care providers.Nurses in basic practice are coordinators of care as well as care givers. They integrate the processes of patient P.123service delivery, patient preparation for various tests or procedures, and the monitoring of patient responses to nursing interventions and the interventions of various health care providers.Advanced Nursing PracticeAdvanced practice registered nurses have acquired the knowledge base and practice experiences to prepare them for specialization, expansion, and advancement in practice. Specialization is concentrating or delimiting one’s focus to part of the whole field of nursing. Expansion refers to the acquisition of new practice knowledge and skills, including knowledge and skills legitimizing role autonomy within areas of practice that overlap traditional boundaries of medical practice. Advancement involves both specialization and expansion and is characterized by the integration of theoretical, research-based, and practical knowledge that occurs as a part of graduate education in nursing.As advanced practice nursing evolved in the roles of clinical nurse specialist, nurse practitioner, nurse midwife, and nurse anesthetist, different components or characteristics of advanced practice nursing were adopted. Most nursing organizations and regulatory bodies now recommend or require all the components of advanced practice nursing—specialization, expansion, and advancement— for nurses assuming advanced practice roles.The nurse in advanced practice acquires specialized knowledge and skills through study and supervised practice at the master’s or doctoral level in nursing. The content of study in the specialty area includes theories and research findings relevant to the core of specialization. The expansion of practice skills is acquired through faculty-supervised practice. Certification is sought following completion of the advanced practice registered nurse’s graduate study.P.124Most nursing organizations and regulatory bodies now recommend or require all the components of advanced practice nursing—specialization, expansion, and advancement—for nurses assuming advanced practice roles.The term advanced practice is used to refer exclusively to advanced clinical practice. Nursing practice requires that some nurses assume other advanced roles in the profession—e.g., educator, administrator, and researcher. These roles are critical to the preparation of nurses for practice, the provision of environments conducive to nursing practice, and the continued development of the knowledge base that nurses use in practice. Although nursing educators, administrators, and researchers are prepared educationally at the master’s or doctoral level, they are not considered advanced practice registered nurses unless they possess advanced practice knowledge and skills in addition to their expertise in education, research, or administration.Professions respond to the needs of society by identifying appropriate areas of specialization. As trends evolve and potential new areas of advanced practice nursing are identified, graduate programs are established by universities, the institutions with primary social responsibility for the education of scientists and professionals. Among the criteria universities use to decide that a new area of practice merits establishment of a program are:[black four-pointed star] The practice area lies within or would be a reasonable expansion of nursing’s scope of practice.[black four-pointed star] A documented need exists for health care in that area of practice.[black four-pointed star] There is a body of knowledge upon which the practice can be based.[black four-pointed star] Faculty are available who are expert in that area by reason of clinical experience and expert knowledge.[black four-pointed star] There is ample evidence that the field of nursing P.125would be diminished if the recognized need were ignored.The scope of advanced nursing practice is distinguished by autonomy to practice at the edges of the expanding boundaries of nursing’s scope of practice. One hallmark of advanced practice nursing—whether in the primary care setting, the community, or the hospital—is the preponderance of self-initiated treatment regimens, as opposed to dependent functions (i.e., actions taken in response to treatments initiated by other health care providers). Because of the expanded practice and knowledge base, advanced practice nursing is also characterized by a complexity of clinical decision making and a skill in managing organizations and environments greater than that required for the practice of nursing at the basic level.The scope of advanced nursing practice is distinguished by autonomy to practice at the edges of the expanding boundaries of nursing’s scope of practice.The advanced practice registered nurse works with individuals, families, groups, and communities to assess health needs; develop diagnoses; plan, implement and manage care; and evaluate outcomes of care. Within their specialty areas, advanced practice registered nurses may also plan and advocate care that promotes health and prevents disease and disability; direct care or manage systems of care for complex patient/family/community populations; manage acute and chronic illness, childbirth, and the care of patients before, during, and after anesthesia; and prescribe, administer, and evaluate pharmacological treatment regimens.In addition, advanced practice registered nurses serve as mentors, consultants, and educators of nurses in basic practice. They conduct research to expand the knowledge base of nursing practice, provide leadership for practice changes, and contribute to the advancement of the profession, the health care sector, and society as a whole.P.126REGULATION OF NURSING PRACTICENursing, like other professions, is responsible for ensuring that its members act in the public interest in the course of providing the unique service society has entrusted to them.Professional RegulationThe process by which the profession does this is called professional regulation. Nursing regulates itself by defining its practice base, providing for research and development of that practice base, establishing a system for nursing education, establishing the structures through which nursing services will be delivered, and providing quality review mechanisms such as a P.127code of ethics, standards of practice, structures for peer review, and a system of credentialing.Professional regulation of nursing practice begins with the profession’s definition of nursing and the scope of nursing practice. Professional standards are derived from the scope of nursing practice.ANA, in collaboration with members of its SNAs and members of other nursing organizations:[black four-pointed star] establishes a code of ethics for the profession.[black four-pointed star] establishes a definition of nursing.[black four-pointed star] delineates the scope of nursing practice.[black four-pointed star] establishes standards of clinical nursing practice.[black four-pointed star] promotes the scientific foundations of nursing practice through theory development and research.[black four-pointed star] specifies the appropriate academic credentials for entry into practice at basic and advanced levels, and[black four-pointed star] accredits selected organizations for peer review.The credentialing boards that are associated with ANA and specialty nursing organizations develop and implement certification examinations and procedures for nurses who want to have their specialty practice knowledge recognized by the profession. Certification is a judgment of competence made by nurses who are themselves practicing within the area of specialization. One component of the required evidence is successful completion of an examination that tests the knowledge base for the selected area of practice. Other requirements relate to the content of course work and amount of supervised practice.P.128Legal RegulationAll nurses are legally accountable for actions taken in the course of nursing practice as well as actions delegated by nurses to others assisting in the delivery of nursing care. Such accountability arises from the legal regulatory mechanisms of licensure and criminal and civil statutes.All nurses are legally accountable for actions taken in the course of nursing practice as well as actions delegated by nurses to others assisting in the delivery of nursing care.Legal contracts between society and the professions are defined by statutes and associated regulations. State nurse practice acts and related legislative and regulatory initiatives serve as the codification of nursing’s obligation to act in the best interests of society. Nurse practice acts grant nurses the authority to practice and grant society the authority to sanction nurses who violate the norms of the profession and act in a manner that threatens public safety.Society is best served when consistent definitions of the scope of nursing practice are used by states: geographic mobility of nurses is enhanced and residents of every state have access to the full range of services that nurses are able to provide. Statutory definitions of nursing should be compatible with the profession’s definition of its practice base but general enough to provide for the dynamic nature of an evolving scope of nursing practice.As advanced practice nursing has evolved, approaches to legal regulation have been based on varying interpretations of societal need and the political philosophies of state constituencies. For both professional and legal regulatory mechanisms, the goal is consistent definitions and criteria for recognition of advanced practice.Self-RegulationNurses exercise autonomy and freedom within their scope of practice. This autonomy and freedom is based upon nurses’ commitment to self-regulation and accountability for practice.P.129One form of self-regulation is accountability for the knowledge base for practice. Nurses develop and maintain current knowledge and skills through formal and continuing education and, where appropriate, seek certification in their areas of practice as a method of demonstrating this accountability.Nurses also regulate themselves as individuals through peer review of their practices. Peer review is the mechanism by which nurses are held accountable for practice based on the profession’s code of ethics. Peer evaluation fosters the refinement of knowledge, skills, and clinical decision-making processes at all levels and in all areas of clinical practice.P.130CONCLUSIONNursing’s Social Policy Statement includes a description of nursing in the United States—the values and social responsibility of the profession, nursing’s definition and scope of practice, nursing’s knowledge base, and the methods by which nursing is regulated. The statement is both an accounting of nursing’s professional stewardship and an expression of nursing’s continuing commitment to the society it serves.P.131REFERENCES1. American Nurses Association. 1980. Nursing: A social policy statement. Kansas City, MO: the Author.2. Page, B.B. Who owns the profession? Hastings Center Report 5:5 (October 1975): 7-8.3. Donabedian, A. 1976. Foreword in M. Phaneuf, ed. The nursing audit: Self-Regulation in nursing practice, 2nd ed., p. 8. New York: Appleton-Century-Crofts.4. Pender, N. 1987. Health promotion in nursing practice, 2nd ed., p. 27. Norwalk, CT: Appleton & Lange.5. Nightingale, F. 1859. Notes on nursing: What it is and what it is not. London: Harrison and Sons. (facsimile edition, 1946. Philadelphia: J.B. Lippincott Company).6. Henderson, V. 1961. Basic principles of nursing care, p. 42. London: International Council of Nurses.7. McCormick, K.A., Lang, N., Zielstorff, R., Milholland, K., Saba, V., Jacox, A. 1994. Toward standard classification schemes for nursing language: Recommendations of the American Nurses Association Steering Committee on Databases to Support Clinical Nursing Practice. Journal of the American Medical Informatics Association 1:421-427.8. McCloskey, J.C., and Bulecheck, G. M., eds. 1996 (in press). Nursing interventions classification (NIC), 2nd ed. St. Louis: Mosby Year Book.9. Benner, P. 1984. From novice to expert: Excellence and power in clinical nursing practice. Reading, MA: Addison-Wesley.10. American Nurses Association. 1991. Standards of clinical nursing practice. Washington, DC: American Nurses Publishing.Appendix D.Nursing: A Social Policy Statement (1980)The content in this appendix is not current and is of historical significance only.P.134P.135ContentsPrefacevIntroduction1I. The Social Context of Nursing3Some Current Social Concerns and Directions in Health Care3Selected Specific Areas of Concern to Nursing5A Nursing View of Working Relationships in Health Care6Authority for Nursing Practice7II. The Nature and Scope of Nursing Practice9A Definition of Nursing9Scope of Nursing Practice13III. Specialization in Nursing Practice21Criteria for Specialists in Nursing Practice23Role and Functions of Specialists in Nursing Practice25Need for Specialists in Nursing Practice27Areas of Specialization27Conclusion30References31P.136PrefaceDuring 1979 the Committee of Chairpersons of the American Nurses’ Association adopted as a goal the development of a coherent policy on nursing resources and coordinated strategy for implementation of the policy, including appropriate credentialing and establishment of qualifications for entry into nursing practice. A series of program activities were proposed to achieve that goal. The chairpersons determined that the Congress for Nursing Practice should assume responsibility for defining the nature and scope of nursing practice, including a description of the characteristics of specialization in nursing. The intent of the chairpersons was that the completed document serve as the basis for ANA policy.The Congress for Nursing Practice is the structural unit of the American Nurses’ Association charged by the Bylaws with responsibility for activities dealing with the scope of nursing practice, legal aspects of nursing practice, public recognition of the significance of nursing practice to health care, and the implications for nursing practice of trends in health care.To accomplish this work, the Congress for Nursing Practice appointed a seven-member task force. The congress acknowledges the significant contributions to the advancement of nursing practice made by the task force, and expresses its particular appreciation of the contributions to that group by Hildegard Peplau and Maria Phaneuf. Their distinguished careers have helped to shape the nursing profession, and their continuing commitment to the profession is demonstrated by their indispensable participation in the work of the task force.The Congress for Nursing Practice is indebted to the ANA Divisions on Practice and practice councils, and to the many other nurses, both individuals and groups, who reviewed and commented on a draft of this statement circulated in June 1980. To those nurses who attended the forum on the draft held at the ANA biennial convention in Houston, Texas, in June 1980, and to those who responded verbally or in writing to the draft, the congress expresses its gratitude for the interest and insights they shared.The congress also acknowledges its appreciation of the work of ANA staff in preparation of the statement, especially that of Katherine Goldring, editor of publications, and Ruth Lewis, director of the Nursing Practice Department.Norma Lang Ph.D., R.N., F.A.A.N.ChairpersonAmerican Nurses’ AssociationCongress for Nursing PracticeP.137IntroductionDuring the last century, the question, “What is nursing?” has been raised by nurses as well as by other health professionals, legislators, and the public. During these years, nursing has steadily responded by moving forward in its conception of its work in consonance with evolving professional and social demands. Trends well under way in nursing must now be reflected in a contemporary delineation of the nature and scope of nursing practice and a description of the characteristics of specialization in nursing.As the professional society for nursing in the United States, the American Nurses’ Association is responsible for defining and establishing the scope of nursing practice. Publication of this statement enhances ongoing professional dialogue and contributes to the work of nursing’s professional society in carrying out its responsibility.The statement includes emphasis on specialization because the development of specialization in nursing practice has been a major advance in nursing during the last three decades. The profession is therefore obliged to provide means of identifying within nursing and for the public those nurses who meet stipulated criteria as specialists, so as to assure the public that those nurses who present themselves as specialists are so qualified.The nursing profession has reached a maturity that not only justifies but also requires a statement affirming nursing’s social responsibility, made in recognition of society’s right to know how that responsibility is exercised in nursing practice. The nature and scope of nursing practice and characteristics of specialization in nursing have therefore been delineated here in a social policy statement.This statement is intended as a fundamental and undergirding delineation, providing a foundation that promotes unity in nursing in a basic and common approach to practice. The statement presents facts and values in nursing as they govern relationships to the larger professional and social context. It provides enabling definitions and descriptions, seeking to clarify the direction in which nursing has evolved and to provide a means for distinguishing between desirable and undesirable directions for future development. It is hoped that this formulation of nursing’s social responsibility will further the growth of the profession and the development of nursing theory.This delineation of the nature and scope of nursing practice is tailored to the diversity, openness, and transition characteristic of the present, P.138actual range of nursing practice. Attempts to conceptually delimit nursing more clearly than it is actually delimited would have been potentially harmful. Such attempts would not only have been unjust to many nurses, but could be used prematurely or arbitrarily to limit the scope of nursing practice; care has been taken to avoid both of these pitfalls.The statement is intended for use by nurses in achieving a fresh perspective on their practice, in helping the profession to move forward at a speed consistent with soundness and based on the achievements already attained, and in giving society a current view of the nature of nursing practice.Useful as definitions and descriptions may be, they cannot accomplish what only political processes can achieve. Neither definitions nor descriptions can determine the actual scope of practice over the years ahead. Nor can they determine the relationships within nursing, between nursing and other health professions, between nursing and the various publics it serves, or between nursing and governmental bodies that formulate and direct implementation of public policy pertinent to health care systems, including the education of health professionals. It is individuals and groups working together through political processes who make these determinations. Because this social policy statement on the nature and scope of nursing practice, including its description of the characteristics of specialization in nursing, attests to nursing’s social responsibilities, use of it by the individuals and groups who make the determinations that influence current developments and the shape of the future is essential.The 1980s have been identified as a decade of decision in nursing. The social policy statement has been so cast as to facilitate decisions through which nursing can consolidate achievements of the past and move with wisdom and courage into its future of service to society.P.139I. The Social Context of NursingNursing, like other professions, is an essential part of the society out of which it grew and with which it has been evolving. Nursing can be said to be owned by society, in the sense that nursing’s professional interest must be and must be perceived as serving the interests of the larger whole of which it is a part. The mutually beneficial relationship between society and its profession has been expressed as follows:A profession acquires recognition, relevance, and even meaning in terms of its relationship to that society, its culture and institutions, and its other members. Professions acquire recognition and relevance primarily in terms of needs, conditions, and traditions of particular societies and their members. It is societies (and often vested interests within them) that determine, in accord with their different technological and economic levels of development and their socioeconomic, political and cultural conditions, and values, what professional skills and knowledge they most need and desire. By various financial means, institutions will then emerge to train interested individuals to supply those needs.Logically, then, the professions open to individuals in any particular society are the property not of the individual but of society. What individuals acquire through training is professional knowledge and skill, not a profession or even part ownership of one.1Some Current Social Concerns and Directions in Health CareHealth care is currently a major focus of attention in the United States. Public and political determinations are being made in five major areas, in each of which nursing has leadership responsibilities:Organization, delivery, and financing of health care. Attention to this area has been sharpened by the costs of care, which threaten to rise beyond the finite national economic capabilities, and by a public morality that requires a general availability, accessibility, and acceptability of health care.Continuing development of health resources, including facilities and manpower for personal care and community health services, in a manner consistent with available knowledge and technology, and an increasing focus on individuals, families, and other groups as basic self-help resources.P.140Provision for the public health through use of preventive and environmental measures, and increased assumption of responsibility by individuals, families, and other groups as basic self-help resources.Development of new knowledge and technology through research.Health care planning as a matter of national policy and related regulations, made specific by the National Health Planning and Resources Development Act of 1974 (Public Law 93-641).In these and other areas, public determinations find expression through political processes carried out by governmental and voluntary bodies. The political process includes the identification of public needs and demands and of the resources available to meet them, combined with appropriation and allocation of funds to support the resources. The political process also can be and is used to shape public perceptions of needs, and thus to create public demands. At best, such use of the political process is made out of impartial concerns for the public good. At worst, it occurs for the advancement of vested interests, with the public good being of lesser or no concern. For nursing, the public good must be the overriding concern.Through political channels in our democracy, public determinations in the five areas previously mentioned are being made in a time of transition from a disease-oriented to a health-oriented system of health care. The transition is occurring in part because of the rising costs of hospital and related medical care. When the costs of the care of the sick rise so strikingly, questions are raised about the possibility of reducing costs by preventing or controlling disease or illness by focusing on attaining, maintaining, and regaining health.Transition from a disease-oriented to a health-oriented system of care is an evolutionary process; such processes occur over time, at a slow pace, and they are often characterized by some denial that change is occurring or that it is even possible. Health care planning as a matter of national policy is evidence that change to a health-oriented system has at least been initiated. This new focus is symbolized by the use of the words health care in place of medical care and by the increasing use of the term health center for hospital. The newly perceived importance of ambulatory care, primary care, and family care centers, home health services, and other patterns of care, the increasing utilization of such types of care, and the provision of public and private payment for it clearly show the impact of the evolving health orientation.P.141While the health orientation can help to prevent, modify, or limit disease or illness, it cannot eliminate them. This change in approach in no way detracts from professional or institutional responsibility for care of the sick. In the movement to a health-oriented system of care, care of the sick remains a basic responsibility.What is equally important is the growing realization that individuals, families, and groups have considerable responsibility for their personal health and for development of their potentials for achieving it. A public increasingly knowledgeable about health and health care systems is becoming more and more involved in related public and political decisions.The decisions to come will be influenced by experience during the past two decades. The decade of the 1960s was characterized by the national spending of health care dollars without interfering in any way with the existing structure of the health care system. The decade of the 1970s was an era of new regulations designed to control the financial obligations resulting from the spending in the sixties. Regulation in its various forms was expensive, poorly designed, and largely ineffective.2It is logical to anticipate that the 1980s will be a decade of increasing regulations with regard to the quantity, costs, and quality of health care. Because these elements are inextricably interwoven, increased attention will be concentrated on social and political options in health care. The development of social and political priorities for action will depend on choice among options, based on society’s values and its needs.Selected Specific Areas of Concern to NursingNursing helps to serve society’s interests in the area of health. The nursing profession has made and continues to make a substantial contribution toward evolution of a health-oriented system of care. Nursing practice has been health-oriented for more than half a century, partly because of its focus on individuals as persons and on the family as the necessary unit of service. In nursing so practiced, the current health movement was foreshadowed.Health is a dynamic state of being in which the developmental and behavioral potential of an individual is realized to the fullest extent possible. Each human being possesses various strengths and limitations resulting from the interaction of environmental and hereditary factors. The relative dominance of the strengths and limitations determines an individual’s place on the health continuum; it determines the person’s biological and behavioral integrity, his wholeness.3P.142During periods of illness, trauma, or disability, an individual or family may require varying degrees of personal assistance in coping with a manifest problem, with the treatment plan designed to alleviate the problem, or with the sequelae. An individual or family may require varying degrees of assistance to obtain information in matters of health, to receive anticipatory guidance and therapeutic counseling to resolve problems, or to manage usual health practices, both during periods of wellness and when faced with a progressive or long-term health problem.Viewed in this light, health becomes the center of nursing attention, not as an end in itself, but as a means to life that is meaningful and manageable.4 Professional practice entails recognition that:Man has an inherent capacity for change in constructive and destructive directions. Access to opportunities for growth and possible change is every person’s right, regardless of social or economic status, personal attributes, or the nature of the health problems…. Individual differences influence not only a person’s potential for change, but also the meanings and values associated with it. Helping services that are founded on respect for human dignity recognize possibilities for individual freedom of choice and enhance opportunities for conscious self direction.5A Nursing View of Working Relationships in Health CareThe nursing profession is particularly concerned with the working relationships essential to the carrying out of its health-oriented mission. The complexity and size of the health care system and its transitional state, increasing public involvement in health policy and a national focus on health, and the professionalization of nursing—all of these factors combine to intensify the importance of the direct human interactions inherent in nursing’s response to human needs and society’s expectations.Nursing involvement in these interactions needs to be carried on with explicit assessment of the nature of working relationships. Conceptually there are three basic types of working relationships.6 The first and most primitive is the one in which one person commands another. The second type can be identified as detente. The third level is collaboration.In the first type, the person with power gives the command, which another obeys. In so commanding, the assumption is usually made that little knowledge, few skills, and little or no judgment or initiative are entailed in responding to the command. In health care, that assumption is generally false; the human beings involved have the P.143capacity to exercise judgment, as warranted by the relevant knowledge and skills. This first level is essentially the master-slave relationship.Detente implies power on both sides that is recognized by both, a recognition and acceptance of separate spheres of activity and responsibility, reciprocal acceptance of the legitimate interests of both parties, and some mutuality of interests and commonality of goals that are recognized by both parties. Detente may be likened to armed neutrality. It is a little-acknowledged prerequisite to genuine collaboration.Collaboration means true partnership, in which the power on both sides is valued by both, with recognition and acceptance of separate and combined spheres of activity and responsibility, mutual safeguarding of the legitimate interests of each party, and a commonality of goals that is recognized by both parties. This is a relationship based upon recognition that each is richer and more truly real because of the strength and uniqueness of the other.In practice, working relationships are rarely pure in type, even within individuals. Working relationships generally combine characteristics of the three types and vary with specific circumstances. In groups and in society as a whole there has been movement away from the command-obey type of relationship, through the detente type of interaction, toward collaboration, due to changes of a social and political nature affecting each of the health professions and the health care system. This change is part of the process of democratization that has been occurring for hundreds of years and has accelerated in the twentieth century.Nursing must recognize and assess the nature of working relationships with patients and families, and with other health professionals and health workers, as well as relationships within nursing and between nursing and representatives of the public at large.Authority for Nursing PracticeThe authority for nursing, as for other professions, is based on a social contract, which in turn derives from a complex social base.There is a social contract between society and the professions. Under its terms, society grants the professions authority over functions vital to itself and permits them considerable autonomy in the conduct of their own affairs. In return, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality in performance is at the heart of this relationship. It is the authentic hallmark of a mature profession.7P.144As is necessary to a profession, nursing has a professional society— the American Nurses’ Association — through which its responsibility to a society as a whole is exercised. Nursing’s professional society performs an essential function in articulating and strengthening, as well as maintaining, the social contract that exists between nursing and society, upon which the authority to practice nursing is based.That social contract has been made specific through the professional society’s work derived from the collective expertise of its members, such as (1) establishing a code of ethics8; (2) establishing standards of practice9; (3) fostering development of nursing theory, derived from nursing research into those conditions that are the focus of practice, so as to explain observations and guide nursing actions; (4) establishing educational requirements for entry into professional practice10; (5) developing certification processes for the profession; and (6) other developmental work directed toward making more specific nursing’s accountability to society.One of the consequences of these and other of nursing’s self-regulatory activities has been enactment of nursing practice acts and related licensure legislation and regulations that make specific the legal authority to practice. This legal authority to practice stems from the social contract between society and the profession; the social contract does not derive from legislation.P.145II. The Nature and Scope of Nursing PracticeA Definition of NursingIn Nightingale’s Notes on Nursing: What It Is and What It Is Not, published in 1859, nursing is defined as to have “charge of the personal health of somebody … and what nursing has to do … is to put the patient in the best condition for nature to act upon him.”11 A century later, Henderson defined nursing as “to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.”12These definitions illustrate the consistent orientation of nurses to the provision of care that promotes well being in the people served. The nursing profession remains committed to the care and nurturing of sick and well people, individually and in groups.The definition of nursing presented here maintains this historical orientation and at the same time reflects the influence of nursing theory that is a part of nursing’s evolution:Nursing is the diagnosis and treatment of human responses to actual or potential health problems.This definition is based on language proposed in 1970 by the New York State Nurses Association.13 This language was adopted as part of the Nurse Practice Act of New York State in 1972 and later incorporated in the nursing practice acts of several other states.14, 15This definition points to four defining characteristics of nursing: phenomena, theory application, nursing action, and evaluation of effects of action in relation to phenomena.Phenomena: The phenomena of concern to nurses are human responses to actual or potential health problems. Any observable manifestation, need, condition, concern, event, dilemma, difficulty, occurrence, or fact that can be described or scientifically explained and is within the target area of nursing practice is of interest to nurses. The human responses of people toward which the actions of nurses are directed are of two kinds: (1) reactions of individuals and groups to actual health problems (health-restoring responses), such as the impact of illness effects upon the self and family, and related self-care needs; and (2) concerns of individuals and groups about potential health P.146problems (health-supporting responses), such as monitoring and teaching in populations or communities at risk in which educative needs for information, skill development, health-oriented attitudes, and related behavioral changes arise.Nursing addresses itself to a wide range of health-related responses observed in sick and well persons. Those responses can be reactions to an actual problem, such as a disease, or they can anticipate a potential health problem. The difference between the response to a health problem and the problem itself is worth noting, as it is here where an intermeshing and complementarity of the distinct foci of the practices of nursing and medicine occur. Human responses to health problems, the phenomena to which the actions of nurses are directed, are often multiple, episodic, or continuous, fluid, and varying, and are less discrete or circumscribed than medical diagnostic categories tend to be.The following provides an illustrative list rather than a comprehensive taxonomy of the human responses that are the focus for nursing intervention:Self-care limitationsImpaired functioning in areas such as rest, sleep, ventilation, circulation, activity, nutrition, elimination, skin, sexuality, and the likePain and discomfortEmotional problems related to illness and treatment, life-threatening events, or daily life experiences, such as anxiety, loss, loneliness, and griefDistortion of symbolic functions, reflected in interpersonal and intellectual processes, such as hallucinationsDeficiencies in decision making and ability to make personal choicesSelf-image changes required by health statusDysfunctional perceptual orientations to healthStrains related to life processes, such as birth, growth and development, and deathProblematic affiliative relationships.The nature of phenomena to which the actions of nurses are directed is ascertained by assessment in its various forms, such as observation, interviewing, measurement, and the like. Instruments for the measurement of conditions within the purview of nursing are being developed and tested through nursing research.16Diagnosis is a beginning effort to objectify a perceived difficulty or need by naming it, as a basis for understanding and taking action to resolve the concern. A nurse’s conceptualization or diagnosis of a presenting condition is a way of ascribing meaning to it, which may or may not accurately reflect the phenomenon under consideration for treatment. Both the diagnosis and its theoretical interpretation are open to revision; indeed, in some modalities, such as psychotherapy, diagnostic revision is simultaneous with the ongoing therapeutic work.Theory: Nurses use theory in the form of concepts, principles, processes, and the like, to sharpen their observations and to understand the phenomena within the domain of nursing practice. Such understanding precedes and serves as a basis for determining nursing actions to be taken.The theoretical base for nursing is partially self-generated and partially drawn from other fields; the resulting insights are integrated into a foundation for nursing practice. Nursing is primarily an applied science: it uses the results of nursing research (which tend to be specifically related to the human responses of concern to nurses) and it selects theories from many other sciences on the basis of their explanatory value in relation to the phenomena nurses diagnose and treat.The range of theories nurses use includes intrapersonal, interpersonal, and systems theories. Intrapersonal theories explain within-person phenomena. Interpersonal theories aid understanding of interactions between two or more people. Systems theories provide explanations of complex networks or organizations, the dynamics of their parts and processes in interaction. Use of this range of theories is necessary because the various conditions within the purview of nursing cannot be understood in terms of cause-effect relations only, but also require knowledge of system dynamics, pattern and process interactions.When responses to actual health problems are being treated, the nature of the difficulty and its causes (when known) require theory application for full understanding of extant problems. When responses to potential health problems or maintenance of health are the focus for the nursing action, theories that aid conceptualization of optimal P.148functioning of individual capacities and processes and of the dynamics of human systems are applied to determine reordering of behavior or life styles congruent with healthy living. Thus, theory selected for application in nursing practice is chosen for its relevance to the task at hand.The ideas and theories of the individual practitioner influence nursing practice in focus and action. Ideally, the actions of the nurse are taken from a theoretical base that includes an accurate understanding of the phenomena in question and a means for evaluation or readjustment.Actions: The aims of nursing actions are to ameliorate, improve, or correct conditions to which those practices are directed, to prevent illness, and to promote health. Ideally, actions are taken on the basis of understood fact (phenomena). In carrying out nursing care, highly developed technical and interpersonal skills are equally as important as the sensitive observation and intellectual competencies required for the nurse in the nursing situation to arrive at a diagnosis (explanation of a problem at hand) and determination of beneficial nursing actions to be taken. Treatment of a diagnosed condition involves nursing actions that can be described and explained theoretically as to their relation to phenomena and expected outcomeEffects: Nursing actions are intended to produce beneficial effects in relation to identified responses. It is the results of the evaluation of outcomes of nursing actions that suggest whether or not those actions have been effective in improving or resolving the conditions to which they were directed. The results of research study of the relation of particular actions to specific phenomena, determined under controlled conditions, provide more rigorous scientific evidence of beneficial effects to nursing actions than does periodic evaluation or testimonials as to effectiveness.Nursing values an approach to practice in which investigation and action are interrelated. This approach is apparent in the four characteristics of nursing, which have been described, and is reflected in the use of the nursing process, which serves as an organizing framework for practice.The nursing process encompasses all significant steps taken in the care of the patients, with attention to their rationale, their sequence, and relative importance in helping the patient reach specified and attainable health goals. The nursing process requires a systematic approach to the assessment of the patient’s situation, which includes reconciliation of patient/family and nurse perceptions of the situation; a plan for nursing actions, which includes P.149patient/family participation in goal setting; joint implementation of the plan; and evaluation which includes patient/family participation. The steps in the process are not necessarily taken in strict sequence beginning with assessment and ending with evaluation. The steps may be taken concurrently and should be taken recurrently, as in the evaluation of the assessment or the plan of action.17Recognition of the nursing process is reflected in the ANA Standards of Nursing Practice, which apply to all nursing practice. These standards, published by the professional society in 1973, provide one broad basis for evaluation of practice and reflect recognition of the rights of the person receiving nursing care. The standards describe a “therapeutic alliance” of the nurse and the person for whom she or he provides care through use of the nursing process.18The relationship between the characteristics of nursing, the nursing process, and the standards that reflect it are shown in Figure 1. The characteristics of phenomena and theory application are implicit in the standards involving data collection, diagnosis, and planning; that of action is referenced in the standards involving planning and treatment; and the characteristic of effects is related to the standards involving evaluation and revision.Scope of Nursing PracticeNursing is a segment of the health care system. In addition to the care an individual provides for his own health, health care is provided through the services of many professions, including nursing, medicine, pharmacy, social work, and dentistry, among others. The term health care is therefore not synonymous with nursing care or medical care, but refers to a composite of planned care provided by interdependent professions whose members collaborate with individuals and groups being served. Health care includes many professional segments, each of which has its own definite characteristics and independent functions.As is true for any profession, the continuity, growth, and thriving of nursing are contingent upon education, research, and administration. Other statements of the American Nurses’ Association describe these components of the nursing profession.19, 20, 21The scope of nursing practice, the contents of the nursing segment of health care, has four defining characteristics: boundary, intersections, dimensions, and core.P.150View FigureFIGURE 1. Defining Characteristics of Nursing Practice: Relationship to the Nursing Process and the Standards of Nursing PracticeP.151View FigureFIGURE 1. ContinuedP.152Boundary: The nursing segment of health care has an external boundary that expands outward in response to changing needs, demands, and capacities of society. As is true of all professions, nursing is dynamic rather than static. As new needs and demands impinge upon nursing, and as a consequence of nursing research, the other three defining characteristics of scope begin to change, resulting in expansion of the boundary.Intersections: The nursing segment of health care intersects with other professions involved in health care. These interprofessional interfacings are meeting points at which nursing extends its practice into the domains of other professions. These intersections are not hard and fast lines separating nursing from another profession; the relations between nursing and medicine at these interfacings are especially fluid and unproblematic in situations in which collegial, collaborative joint practice obtains.22 All of the health care professions interact, share the same overall mission, have access to the same published scientific knowledge, and in some degree overlap in their activities.A statement of the scope of nursing ought not to limit the boundary or fix the intersections of nursing with other professions, but should allow for expansion and flexibility. Individual nurses, however, do limit the scope of their practice in light of their education, knowledge, competence, and interest. These differences constitute intraprofessional intersections. All nurses locate themselves somewhere within the scope of nursing on the basis of preparation for the work. Tolerance of differences in interests, in part or whole, and intraprofessional collaboration among nurses serve their shared mission: to promote health.Core: The core of nursing practice is the basis for nursing care—the phenomena previously described. These conditions are brought into focus by naming or diagnosing them, or by hypothesizing or inferring when the facts are unclear or no diagnosis exists. Diagnosis of phenomena leads to application of theory to explain the condition and to determine actions to be taken—otherwise, diagnosis is mere labeling.The range of diagnostic categories within the scope of nursing practice is constantly undergoing expansion. The American Nurses’ Association, through its five Divisions on Nursing Practice, has identified and is further formulating the phenomena of concern that lie within the scope of responsibility of professional nurses. Various individuals and groups are presently developing classification systems of nursing diagnoses.23, 24, 25Dimensions: The dimensions of nursing practice are characteristics that fall within and further describe the scope of nursing. A comprehensive P.153statement of these characteristics would include but not be limited to descriptions of what philosophy and ethics guide nurses; what responsibilities, functions, roles, and skills characterize their work; what scientific theories they use and by what methods they apply them; where and when they practice; and with what legal authority nurses function.View FigureFIGURE 2. Characteristics of the Scope of Nursing PracticeP.154One of the most distinguishing characteristics of nursing is that it involves practices that are nurturant, generative, or protective in nature.26 They are developed to meet the health needs of individuals as integrated persons rather than as biological systems. The nurturant or nurturing behaviors provide comfort and therapy in the presence of illness or disease and foster personal development. The generative behaviors are oriented to development of new behaviors and modification of environments or systems to promote health-conducive adaptive responses of the individuals to health care crises or problems. The protective behaviors involve surveillance, assessment, and intervention in support of adaptive capabilities and developmental functions of persons. These nurse behaviors are responsive to people with conditions diagnosed and treated by nurses as they apply theory in order to explain and to guide nurse action in practice.Nurses are guided by a humanistic philosophy having caring coupled with understanding and purpose as its central feature. Nurses have the highest regard for self-determination, independence, and choice in decision making in matters of health. Recognizing that illness and physical handicap tend to erode these attributes of persons, nursing throughout its history has provided health teaching, sharing its expertise with the public through, for example, courses in home health nursing. Presently, nursing is directing its attention to evolving theory and practices focusing on the responsibility of the individual for his own health.Nurses are committed to respecting human beings because of a profound regard for humanity. This principle applies to themselves, to people receiving care, and to other people who share in the provision of care, as well as to humanity in general.This basic commitment is unaltered by the social, educational, economic, cultural, racial, religious, or other specific attributes of the human beings receiving care, including the nature and duration of disease and illness.Nursing care is provided in an interpersonal relationship process of nurse-with-a-patient, nurse-with-a-family, nurse-with-a-group. It involves privileged intimacy—physical and interpersonal. Nursing is a laying-on-of-hands practice in which nurses have access to the body of another person in carrying out assessments, comfort care, and definitive P.155treatments. At best, nurses carry out such physical ministrations with compassion and with recognition of the client’s dignity. Nursing is a practice in which interpersonal closeness of a professional kind develops and aids the investigation and discussion of problems, as nurse and patient (or family or group) seek jointly to resolve those concerns. Nursing therefore includes an array of functions, including physical care, anticipatory guidance, health teaching, counseling, and the like.Nursing practice demands professional intention and commitment carried out in accordance with the American Nurses’ Association Standards of Nursing Practice and its ethical code. While all nurses are responsible for practicing in accordance with the ANA Standards of Nursing Practice, the level and sophistication of application vary with the education and skills of the individual nurse. Nursing is practiced by nurses who are generalists and by nurses who are specialists. Each nurse remains accountable for the quality of her or his practice within the full scope of nursing practice.Generalists in nursing provide most of the care for most of the people served by nursing. In other words, in numbers and in amount of service provided, generalists provide the bulk of nursing care. The care provided by these nurses should be available to people wherever they may be at a given point in time and whatever may be their situation in terms of health, disease, illness, or injury at the time. The nurse generalist has a comprehensive approach to health care and can meet diversified health concerns of individuals, families, and communities.Specialists in nursing are experts in providing care focused on specific clusters of phenomena drawn from the range of general practice. Specialization involves adding to the generic base of nursing practice an organized and systematized body of knowledge and competencies within a discrete area of nursing, applied through specialized practice. Specialized nursing practice represents a refining of interests, either by focusing upon a part of the whole of nursing practice or by focusing upon relations among parts. The phenomena of concerns selected by specialists in nursing practice may relate either to a specialized field or to the interrelation among specialized fields.All nurses practicing with patients and with persons seeking health address the phenomena that form the core of nursing practice. Variations within nursing practice resulting from differences in level of education, extent of experience, and competence occur in regard to the following:Assessment and data collectionP.156Analysis of dataApplication of theoryBreadth and depth of knowledge base, especially clinical, psychosocial, and patho/physiological theories relating to nursing diagnosis and treatmentThe range of nursing techniquesNeed for, kind, and extent of supervision by other nurses in practiceEvaluation of effects of practiceIdentification of relationships among phenomena, nursing actions, and effects (outcomes for the patients).All nurses are responsible for the inclusion of preventive nursing as part of general and specialized practice. Prevention in nursing is directed to promotion of health and disease prevention; securing prompt attention for medical diagnosis and treatment of disease, or as necessary when predisposition to a given disease is apparent from the nursing diagnosis; and early recognition and management of complications and other consequences due to disease or therapy.Nurses provide care to people in various states of their life span, from birth, through death. Service is provided in environments such as homes, schools, and places of employment, as well as in general and specialty hospitals, ambulatory care settings, skilled nursing facilities, long-term care institutions, protective or custodial institutions, and in newer types of health care settings that are evolving.All nurses are ethically and legally accountable for actions taken in the course of nursing practice as well as for actions delegated by the nurse to others assisting in the delivery of nursing care. Such accountability may be accomplished through the regulatory mechanism of licensure, through criminal and civil laws, through the code of ethics of the profession, and through peer evaluation.P.157III. Specialization in Nursing PracticeSpecialization is a mark of the advancement of the nursing profession. It suggests that nursing has moved from a global to a more specific way of looking at the field and its practices. Instead of homogeneity (a nurse is a nurse is a nurse), there is a heterogeneity of clinical interests and levels of competence within nursing. Such differentiation, which is a criterion of development, is occurring due to the greater complexity within the whole of nursing practice at this juncture in nursing’s history.Specialization means a narrowed focus on a part of the whole field of nursing. It entails application of a broad range of theories to selected phenomena within the domain of nursing, in order to secure depth of understanding as a basis for advances in nursing practice. It requires identification and more concentrated effort toward resolution of heretofore poorly understood questions related to the phenomena of concern to nurses. It involves empirical and controlled research to clarify aspects of a delimited part of the field of nursing, and to generate refinement of existing nursing practices, or to evolve new ones more likely to be more beneficial to clients or patients.Specialization arises in five main ways:The amount and complexity of knowledge and technology create a demand for a few professionals to give special attention to applications in delimited practice areas.A few professional pioneers seek to obtain greater depth of understanding of phenomena related to a segment of nursing and to test new practices intended to correct or ameliorate recognized conditions.Public attention and available funds become focused on an area of practice in which heretofore there has been a lack of interest, knowledge, and skilled practitioners.The complexity of services exceeds the prevailing knowledge and skills of general practitioners, and this problem is approached by intense personal studies or post-basic study by a few interested professionals.Part of a professional field expands, and simultaneously some of its members seek ways for expanded use of their intellectual and other capacities.P.158Specialization in nursing has been discussed since the turn of the century.27 Initially, the term specialist designated nurses who had graduated from specialized hospitals, or private-duty nurses who worked only with particular kinds of patients. As early as 1910, in ANA convention proceedings, nurses were referred to as specialists. These designations, however, were based upon practical experience or indicated completion of hospital-based “post-graduate” courses in the area of nursing. These courses, which used nurses to provide nursing care but offered little by way of education as it is now known, became so numerous by the early 1940s that the National League for Nursing Education established a committee to study this matter. The committee produced guidelines for advanced courses in nursing.28During the same period, advanced clinical courses began to be offered by various colleges and universities, with the assistance of government funds. The number of nurses holding baccalaureates was exceedingly small at the time, and the university-based advanced courses led to either a bachelor’s or a master’s degree.In the 1950s, the meaning of the term advanced clinical nurse began to change as universities offered programs for preparation as “clinical specialists in nursing.”29 It was not until the 1960s, however, that all post-basic education for specialization in clinical nursing was provided in graduate programs. By 1980, over 75 colleges and universities offered such programs.30Specialization in nursing is now clearly established. The process has brought about reexamination and revitalization of the generic foundation in which the specialization is rooted. Requirement of the baccalaureate for entry into professional practice, of advanced learning for specialty practice, administration, and teaching, and of doctoral education that includes focus on research capabilities emerges as necessary to fulfillment of nursing’s social responsibility.Specialization in nursing practice assists in clarifying, revising, and strengthening existing practice. It also permits new applications of knowledge and refined nursing practices to flow from the specialist to the generalist in nursing practice and graduate to basic nursing education, thus ensuring progress in the general practice of nursing.It provides career options, including private practice, for nurses who have particular interests in a part of the nursing field and who seek greater development and use of their abilities as well as increased responsibility and authority in practice. Specialization expedites production of new knowledge and its application in practice. Specialization also provides preparation for teaching and research related to a defined area of nursing.P.159Criteria for Specialists in Nursing PracticeThe specialist in nursing practice is a nurse who, through study and supervised practice at the graduate level (master’s or doctorate), has become expert in a defined area of knowledge and practice in a selected clinical area of nursing. Specialists in nursing practice are also generalists, in that they hold a baccalaureate in nursing, and therefore are able to provide the full range of nursing care. In addition, upon completion of a graduate degree in a university graduate program with an emphasis on clinical specialization, the specialist in nursing practice should meet the criteria for specialty certification through nursing’s professional society.Graduate study for preparation as a specialist in nursing practice includes in-depth study of theories relevant to the particular area of specialization and faculty-supervised clinical practice. Faculty supervision means substantial review of data obtained by the graduate student during clinical practice with clients, families, groups, or communities, whichever is required by the focus of the nurse’s intended specialization. Such supervisory review is provided on a regularly scheduled basis, over a period of time of sufficient length to provide an in-depth picture of the student’s developing competence as a clinical specialist.Those competencies include ability to observe, conceptualize, diagnose, and analyze complex clinical or non-clinical problems related to health, ability to consider a wide range of theory relevant to understanding those problems, and ability to select and justify application of theory deemed to be most useful in understanding the problems and in determining the range of possible treatment options. Ability to foresee and discuss short- and long-range possible consequences is also to be demonstrated. While this is not an exhaustive list, the foregoing intellectual competencies are of the utmost importance in specialization.The faculty member who supervises nurses who are preparing for clinical specialization functions as a role model, demonstrating intense interest in the problems germane to the specialty area and expertise regarding the knowledge and practice of that area. Faculty supervisors are also “gatekeepers,” permitting only those nurses who achieve a higher level of competence for specialty practice to obtain the graduate degree and recommendation for certification as a specialist. All universities that offer graduate programs in nursing practice should be knowledgeable about requirements for certification of specialists and should inform prospective students whether or not the graduate study to be undertaken is congruent with such requirements.P.160Certification of specialists in nursing practice is a judgment made by the profession, upon review of an array of evidence examined by a selected panel of nurses who are themselves specialists and who represent the area of specialization.Specialists in nursing practice thus must meet two primary criteria* (1) an earned graduate degree (master’s degree or doctorate) that represents study of scientific knowledge and supervised advanced clinical practice related to a particular area within the scope of nursing; (2) eligibility requirements for certification through the professional society or completion of the certification process.The purpose of the criteria for specialists in nursing practice is protection of the public. Unlike generalist nurses, who upon licensure and entry into practice are expected to be competent at least at a minimum safe level, specialists are expected to have expert competence. The public relies upon boards of nursing, through which nursing practice acts are administered under the authority of state governments, to assure its safety in regard to the general practice of all nurses. Because specialists in nursing practice hold licenses in the state in which they practice, they are subject to the legal constraints and external (outside the profession) regulations that apply under the nursing practice act.Additionally, however, the public needs clear evidence that a nurse who claims to be a specialist does indeed have expertise of a particular kind. The profession of nursing has a social obligation to the public to satisfy that need, which it does by means of certification of specialists and by accreditation of the graduate programs that educate specialists in nursing practice. These two methods by which the public is protected against false claims are in accord with the prerogative of self-regulation (within the profession) that society has accorded as a trust to its professions. It is in the absence of such within-profession credentialing that the public turns to the law for its protection. Through credentialing of those nurses who claim competence at an expert level, the nursing profession assures the public that these claims of a higher standard of nursing competence are not false.P.161Expert competence is an abstraction—the difference between a generalist and a specialist cannot be seen until it has been made concrete through practice, over time; reliance upon credentialing of specialists by the profession is therefore a safeguard for the consumer who uses the services of a specialist in nursing practice.Role and Functions of Specialists in Nursing PracticeSpecialists in nursing practice have autonomy and freedom in practice greater than do nurses in general practice. The autonomy and freedom are based upon broader authority rooted in expert knowledge in selected areas of nursing. This expert knowledge is associated with greater self-discipline and responsibility for direct care practice and for advancement of the nursing profession. The self-discipline includes seeking periodic review of clinical data from an equally prepared expert in the same specialized area of practice.Nursing is primarily an applied science in that it selects and applies theories from all existing sciences in order to understand and treat those conditions within the scope of nursing. In the last several decades the explosion of knowledge in all scientific fields and the development of nursing research have made monumental the task of theory selection and application in general nursing, and have correspondingly increased the risk of superficiality in this process. Under these circumstances, clinical specialization in nursing has made it possible for some nurses, through graduate-level education, to sharpen their acumen in a designated part of the whole field of nursing.The effectiveness of the profession is increased when specialists are available to focus their efforts around a particular aspect of clinical nursing, to test application of newly available theory to conditions germane to that clinical aspect, to translate those theory applications into nursing approaches considered more useful than prevailing ones, and to assist in encouraging and speeding up the flow of new knowledge into basic nursing education and generalized nursing practice.Characteristic functions of specialists in nursing practice include the following:Identification of populations or communities at riskDirect care of selected patients or clients in any setting, including private practiceP.162Intraprofessional consultation with nurse specialists in different clinical areas and with nurses in general practiceInterprofessional consultation and collaboration in planning total patient care for individual and groups of patients, and in planning and evaluating health programs for population groups at risk related to the specialty or the public in generalContribution to the advancement of the profession as a whole and to the specialty field.It is expected of specialists that they engage in a variety of activities consistent with the aims of the specialty and the profession. These activities include the following:Selective participation in basic, graduate, and continuing education programsParticipation in or the conduct of research related to the area of specializationPreparation of publications derived from clinical practice and related education or research that would contribute to the general advancement of practice and the professionObtaining certification in the area of clinical specialization through the professional society. Such certification, including periodic review, is the profession’s method of assuring the public of the validity of the specialist’s credentials.Legislation to govern specialty practice in nursing should not be sought; all nurses are governed by and liable for practice at the minimum safe levels defined in nursing practice acts. Guidelines for and regulation of practice beyond the basic level of general practice covered by current licensure should be developed within the professional association.Specialty practice is at the growing edge of the profession, and therefore its nature and scope change as new knowledge develops. Those specialists in nursing practice who continue independent study of the problems within an area, especially through empirical research, experience many changes in role and function.When nurse specialists are employed in health care settings, descriptions of their position and functions ought not to be standardized. The work rules for the specialist must be jointly determined and negotiated P.163by the applicant and the employing institution. The emphasis should be on developing negotiated positions and organizational arrangements that are most likely to result in freedom and responsibility for maximum use of the abilities of the particular specialist in the particular health care setting. In joint practices and partnerships, in which nurse specialists practice on a private basis with other nurses or other professionals; joint determination of working arrangements and shared responsibility also apply.Need for Specialists in Nursing PracticeThe need of society and the nursing profession for adequate numbers and kinds of specialists in nursing practice should be monitored periodically by the professional society. While the demands of the marketplace should be allowed to regulate excess in numbers, the profession must take steps to assure that universities prepare enough specialists in nursing practice to meet needs for qualified nurse faculty, nurse researchers, and consultants, as well as specialists for direct care practice.At the same time, the need for specialists must be balanced against the needs of the society and the profession for nurses in general practice. The responsibility of the profession and its specialists for continued strengthening of the generic foundation of nursing is a major one if fragmentation and unjustifiable costs of care are to be avoided in nursing.Areas of SpecializationThe principle applies: Professional organizations do not initiate trends; rather, they formulate and consolidate those trends already under way within the practices of the professions in society. Those trends that have been judged to be promising for the advancement of the profession are pertinent to determination of areas of specialization in nursing. Two major social institutions—universities and the American Nurses’ Association—are involved in the establishment of areas of specialization in nursing.Graduate programs that prepare specialists in nursing practice are initiated, established, and conducted by universities, which have the primary social responsibility for the education of scientists and professionals. Among the criteria universities use to decide that an area of specialization in nursing merits establishment of a program are the following:A previously unrecognized area that lies within or would be a reasonable expansion of nursing’s scope of practice is identified by one or more nurses or by another person.P.164The nursing faculty at the university has identified through careful study that a sufficient need exists in society or in the health care system to warrant preparing nurses for that new area of specialization in nursing. Nurses who are experts in that area by reason of clinical experience, and who either have or could readily obtain the necessary credentials for academic teaching, are available. Furthermore, the expertise of nurse faculty in the area most closely related to the proposed new one could be co-opted to assist in the design and conduct of the proposed new program.There is ample evidence to believe that the whole field of nursing would be diminished or limited in its long-range aim if the recognized need were ignored.Funds in support of the program are available or could be obtained.After universities have been providing graduate programs for specialty practice in nursing and accreditation of those programs is in effect, certification of specialists who graduate from those programs becomes a concern of the profession in exercising its responsibility to the public.The American Nurses’ Association has five Divisions on Nursing Practice: community health nursing, gerontological nursing, maternal and child health nursing, medical-surgical nursing, and psychiatric and mental health nursing. These divisions are interest groups; membership in them is open to any ANA member having an interest in a particular division. Each of the divisions offers certification programs for nurses in their respective fields of practice. Thirteen certification programs in nursing practice are currently offered.Only three of these certification programs are for specialists, i.e. require a master’s or higher degree in the area of specialization: the program for clinical specialists in medical-surgical nursing and the two programs for clinical specialists in psychiatric and mental health nursing. Many of the nurses who have been certified in other programs do hold master’s degrees in their area of specialization, however, and would be eligible for certification as specialists if such programs existed. Many certified family nurse practitioners, for example, hold master’s degrees in their area of specialization that would qualify them as specialists, although the family nurse practitioner certification program does not include a graduate degree among its eligibility requirements.The ANA divisions on nursing practice also provide councils as P.165opportunities for groups of nurses to meet together and share their interests and concerns related to defined areas of nursing practice.The American Nurses’ Association has recognized that most nursing practice is general nursing in a specialized area, having a specialized population or focus. Within the wide variety of health care institutions, most nursing practice occurs as a concentration in an area of nursing, based on interest, experience, and selection of employment, for example. Additionally, public interest and concern about specific areas of health problems stimulates employment opportunities that sometimes coincide with interests of enterprising nurses. Public concern also sometimes stimulates funds for short-term education of nurses, and the movement toward widespread continuing education for nurses has provided short-term concentrated education. Both of these efforts have been aimed at meeting immediate needs for nurses to work more productively in particular areas of nursing practice. Many nurses with less than graduate education have enlarged their competence for work in such areas without being specialists and without having the recognizable credentials of specialists.As the professional society for nursing, ANA must provide structural arrangements that recognize the wide diversity of clinical expertise that exists among nurses—generalists, generalists who concentrate their practice in specialized areas, and qualified specialists in nursing practice—and thereby give recognition of and show tolerance for the difference and complexity that characterize contemporary nursing. This diversity must be seen as a constructive response of nurses to social needs in a time of rapid, complex, and sophisticated changes in present-day health care systems.At the same time, it is incumbent upon the American Nurses’ Association to provide for certification of specialists in nursing practice as a means of assuring the public that those nurses who claim to be specialists in nursing practice are so entitled by virtue of holding an earned graduate degree in the area of specialization and meeting the requirements for certification through the professional society.Within the decades ahead, as a taxonomy of those conditions that nurses diagnose and treat is further refined, new rubrics for emerging clusters of specialization will be formulated within the profession. The American Nurses’ Association must be prepared to provide structural arrangements and programming, including certification, congruent with those areas of specialization.P.166ConclusionIn this statement, nursing and its scope have been defined and issues related to specialization have been presented within the social context in which nurses practice. This social policy statement is intended to assist nurses in conceptualizing their practice; to provide direction to educators, administrators, and researchers within nursing; and to inform other health professionals, legislators, funding bodies, and the public about nursing’s contribution to health care.The statement has defined nursing in terms of the phenomena to which it addresses action (diagnosis and treatment of human responses to actual and potential health problems), its use of theory to guide action, and its evaluation of the effects of action.It has described nursing’s scope of practice in terms of a boundary expanding in response to changing social needs and demands; intersections with the practice of other health professionals; a core that distinguishes nursing from other health professions by virtue of its phenomena of concern; and dimensions that characterize nursing in terms of its practitioners, its practice settings, and its accountability.The statement has traced the growth of specialization within nursing practice, and has identified specialists in terms of criteria related to graduate education and certification through the professional society.Nursing’s social responsibility has been addressed throughout the statement—in its definition of nursing, its delineation of the scope of nursing practice, and its description of specialization in nursing. The statement is thus both an accounting of nursing’s professional stewardship and an expression of its continuing commitment to those its practice serves.P.167References1. Page, B.B. Who Owns the Professions? Hastings Center Report 5:5 (October 1975), 7-8.2. Mechanic, D. Future Issues in Health Care: Social Policy and the Rationing of Health Services. New York: Free Press, 1979, 6-7.3. American Nurses’ Association Division on Maternal and Child Health Nursing Practice. A Statement on the Scope of Maternal and Child Health Nursing Practice. Kansas City, Mo.: the Association, 1980,5.4. Antonovsky, A. Health, Stress, and Coping. San Francisco: Jossey-Bass, 1979, 123.5. American Nurses’ Association Division on Psychiatric and Mental Health Nursing Practice. Statement on Psychiatric and Mental Health Nursing Practice. Kansas City, Mo.: the Association, 1976, 4.6. Phaneuf, M. The Nursing Audit: Self-Regulation in Nursing Practice. 2nd edition. New York: Appleton-Century-Crofts, 1976, 8.7. Donabedian, A. Foreword, in M. Phaneuf, The Nursing Audit: Self-Regulation in Nursing Practice. 2nd edition. New York: Appleton-Century-Crofts, 1976.8. American Nurses’ Association. Code for Nurses With Interpretive Statements. Kansas City, Mo.: the Association, 1976.9. American Nurses’ Association Congress for Nursing Practice. Standards of Nursing Practice. Kansas City, Mo.: the Association, 1973.10. American Nurses’ Association. Educational Preparation for Nurse Practitioners and Assistants to Nurses: A Position Paper. New York: the Association, 1965.11. Nightingale, Florence. Notes on Nursing: What It Is and What It Is Not. London: Harrison and Sons, 1859, preface and 75. (Facsimile edition, J.B. Lippincott Company, 1946.)12. Henderson, Virginia. Basic Principles of Nursing Care. London: International Council of Nurses, 1961, 42.13. New York State Nurses Association. Report of the Special Committee to Study the Nurse Practice Act, September 24,1970,1.14. New York Education Law (McKinney), Article 139, Section 6902.15. Kelly, Lucie Young. Nursing Practice Acts, American Journal of Nursing 7:74 (July 1974), 1315.16. U.S. Health Resources Administration. Instruments for Measuring Nursing Practice and Other Health Care Variables. 2 Vols. (DHEW Publ. No. HRA 78-53) Washington, D.C.: U.S. Government Printing Office, 1979.17. American Nurses’ Association Congress for Nursing Practice. A Plan for Implementation of the Standards of Nursing Practice. Kansas City, Mo.: the Association, 1975, 4-5.18. Standards of Nursing Practice, supra.P.16819. American Nurses’ Association Commission on Nursing Education. Standards for Nursing Education. Kansas City, Mo.: the Association, 1975.20. American Nurses’ Association Commission on Nursing Research. Research in Nursing: Toward a Science of Health Care. Kansas City, Mo.: the Association, 1976.21. American Nurses’ Association Commission on Nursing Services. Standards for Nursing Services. Kansas City, Mo.: the Association, 1973.22. The National Joint Practice Commission. Statement on the Definition of Joint or Collaborative Practice in Hospitals. Chicago: the Commission, 1977.23. Gebbie, Kristine M., and Mary Ann Lavin (eds.). Classification of Nursing Diagnoses, Proceedings of First National Conference. St. Louis, Mo.: C.V. Mosby, 1975,171.24. Gebbie, Kristine M. (ed.). Classification of Nursing Diagnoses, Summary of the Second National Conference. St. Louis, Mo.: Clearinghouse, National Group for Classification of Nursing Diagnosis, 1976, 200.25. Gordon, Marjory. Implementation of Nursing Diagnoses (guest editorial), The Nursing Clinics of North America 14:3.26. Bevis, Em Olivia. Curriculum Building in Nursing: A Process. St. Louis, Mo.: C. V. Mosby, 1978,141.27. Dewitt, K. Specialties in Nursing, American Journal of Nursing 1:1 (October 1900), 14-17.28. NLNE Special Committee on Post-Graduate Clinical Nursing Courses. Courses in Clinical Nursing for Graduate Nurses: Basic Assumptions and Guiding Principles, Basic Courses, Advanced Courses, Pamphlet 2. Livingston, New York: Livingston Press, 1945.29. Burd, Shirley F. The Clinical Specialization Trend in Psychiatric Nursing. Unpublished Ed.D. thesis, Graduate School of Education, Rutgers, The State University of New Jersey, 1966.30. National League for Nursing Division of Baccalaureate and Higher Degree Programs. Master’s Education in Nursing: Route to Opportunities in Contemporary Nursing, 1979-80. New York: the League, 1979.Appendix E.The Development of Foundational Nursing Documents and Professional Nursing: A TimelineThe American Nurses Association has long been instrumental in the development of three foundational documents for professional nursing—its code of ethics, scope and standards of practice, and social policy statement. Each document contributes to further understanding the context of nursing practice at the time of publication and reflects the history of the evolution of the nursing profession in the United States. Advancing communication technologies have expanded the revision process to permit ever-increasing numbers of registered nurses to contribute to the open dialogue and review activities. This ensures that the final published versions not only codify the consensus of the profession at the time of publication, but also reflect the experiences of those working in the profession at all levels and in all settings.1859 Florence Nightingale publishes Notes on Nursing: What It Is and What It Is Not.1896 The Nurses’ Associated Alumnae of the United States and Canada is founded. Later to become the American Nurses Association (ANA), its first purpose was to establish and maintain a code of ethics.1940 A “Tentative Code” is published in The American Journal of Nursing, although never formally adopted.P.1701950 Code for Professional Nurses, in the form of 17 provisions that are a substantive revision of the “Tentative Code” of 1940, is unanimously accepted by the ANA House of Delegates and published.1952 Nursing Research publishes its premiere issue.1956 Code for Professional Nurses is amended and published.1960 Code for Professional Nurses is revised and published.1968 Code for Professional Nurses is substantively revised and published, condensing the 17 provisions of the 1960 Code into 10 provisions.1973 ANA publishes Standards of Nursing Practice, a first for ANA.1976 ANA publishes Standards of Gerontological Nursing Practice, its first such publication for a nursing specialty practice.Code for Nurses with Interpretive Statements, is published, modifying the 1968 Code into 11 provisions and adding interpretive statements.1980 ANA publishes Nursing: A Social Policy Statement.1985 The National Institutes of Health organizes the National Center for Nursing Research.ANA publishes Titling for Licensure.Code for Nurses with Interpretive Statements retains the provisions of the 1976 edition and includes revised interpretive statements.The ANA House of Delegates forms a task force to formally document the scope of practice for nursing.1987 ANA publishes The Scope of Nursing Practice.1990 The ANA House of Delegates forms a task force to revise the 1973 Standards of Nursing Practice.P.1711991 ANA publishes Standards of Clinical Nursing Practice, a revision of the 1973 standards.1995 ANA publishes Nursing’s Social Policy Statement, updating the 1980 work.1995 The Congress of Nursing Practice directs the Committee on Nursing Practice Standards and Guidelines to establish a process for periodic review and revision of nursing standards.1996 ANA publishes Scope and Standards of Advanced Practice Registered Nursing.1998 ANA publishes Standards of Clinical Nursing Practice, 2nd Edition (also known as the Clinical Standards).2001 Code of Ethics for Nurses with Interpretive Statements is accepted by the ANA House of Delegates and published.ANA publishes Bill of Rights for Registered Nurses.2002 ANA publishes Nursing’s Agenda for the Future: A Call to the Nation.2003 ANA publishes Nursing’s Social Policy Statement, 2nd Edition.2004 ANA publishes Nursing: Scope and Standards of Practice, which addresses advanced practice topics.2008 APRN Consensus Model published by the APRN Consensus Work Group and APRN Joint Dialogue Group.ANA publishes Professional Role Competence Position Statement.ANA publishes Specialization and Credentialing in Nursing Revisited: Understanding the Issues, Advancing the Profession.2010 ANA publishes Nursing’s Social Policy Statement: The Essence of the Profession.ANA publishes Nursing: Scope and Standards of Practice, 2nd Edition

Lab7_Fermentation5

BIOL 102: Lab 7Yeast FermentationPRE-LAB ASSIGNMENT: Students are expected to read pages 1-2 before coming to the lab to complete the experiments.Print this entire lab packet and bring it to the laboratory.  Please provide a FULL lab report for this experiment following the “Lab Report Guidelines”.  Please note that this lab report WILL include a HYPOTHESIS.Objectives:Observe yeast fermentationDetermine the optimum conditions for yeast fermentationBackground:All fungi are eukaryotes.  Although they vary in size and shape, fungi share key characteristics including their way of obtaining nutrients for growth and energy.  Fungi are heterotrophs and they depend on preformed carbon molecules produced by other organisms.  However, fungi do not ingest food and then digest it using enzymes; instead they invade -think of a moldy piece of bread-a food source and secrete digestive enzymes onto it.  The digestion occurs outside the body.  When the polymers are broken down into monomers, the fungi absorb the predigested food into its body.Yeast are microscopic, unicellular organisms in the Kingdom Fungi.  Like other fungi, yeast are incapable of making their own food, but like any other organism, need food for energy. They rely on carbohydrates (usually sugars) found in their environment to provide them with this energy so that they can grow and reproduce. There are many species of yeast, and each has a particular food source.  Regardless of the food source, yeast perform fermentation which does not utilize oxygen.  In fermentation, the only energy extraction pathway is glycolysis, with one or two extra reactions tacked on at the end, but no electron transport chain.  Therefore, only 2 ATPs are formed per glucose.Fermentation and cellular respiration begin the same way, with glycolysis. In fermentation, however, the pyruvate made in glycolysis is not completely oxidized because it does not continue through the citric acid cycle and the electron transport chain does not run. Because the electron transport chain is not functional, the NADH cannot drop its electrons off to the electron transport chain, and thus very few ATP molecules are synthesized because the ATP synthase is not running.Based on the end products, fermentation can be of two types: ALCOHOLIC fermentation (the subject of this lab) and LACTIC ACID fermentation. Regardless of the type of fermentation, the purpose of the extra reactions in fermentation, is to regenerate (recycle) the electron carrier NAD+ from the NADH produced in glycolysis. The extra reactions accomplish this by letting NADH drop its electrons off with an organic molecule such as acetaldehyde to produce ethanol (alcoholic fermentation), or pyruvate to produce lactic acid (lactic acid fermentation). This “drop-off” of electrons allows glycolysis to keep running by ensuring a steady supply of NAD+.Going from pyruvate to ethanol is a two-step process. In the first step, a carboxyl group is removed from pyruvate and released as carbon dioxide, producing a two-carbon molecule called acetaldehyde. In the second step, NADH passes its electrons to acetaldehyde, regenerating NAD+ and forming ethanol.Yeast breaks down glucose into ethanol, 2 carbon dioxide molecules, and 2 ATP molecules.  The formula for the yeast fermentation reaction is:  Reactant                                     ProductsC6H12O6  <<<<<<<   2CH3CH2OH + 2CO2+ 2 ATP moleculesFor the yeast cell, this chemical reaction is necessary to produce the energy for life.  The ethanol and the carbon dioxide are waste products.  It is these waste products that we take advantage of: we use the ethanol in alcoholic beverages and the carbon dioxide makes bread rise when baking.Alcoholic fermentation, can be observed and measured by using the amount of carbon dioxide gas that is produced from the breakdown of glucose. In this exercise, you will observe alcoholic fermentation by yeast.  To do so you will add the same amounts of yeast and water to different amounts of sugar in Erlenmeyer flasks and cap them with a balloon to see how much carbon dioxide gas is produced. You will also use water at two different temperatures and determine how much carbon dioxide is produced.  The more fermentation that occurs, the more carbon dioxide will be produced, and the more the balloon will expand.Information adapted from:Solomon, Eldra P. et al. Biology. 10th ed. Cengage, 2015.https://www.khanacademy.org/science/biology/cellular-respiration-and-fermentationLAB DATASHEETDetermine the optimum conditions for yeast fermentation.Think Scientifically:  Please explain your rationale to which flask or test variable will produce the most CO2.  Look at the various bottles below and state whether bottle A-F will produce the most CO2 and explain why. Materials:SugarDry yeastWarm waterIce cold waterBalance scaleMeasuring spoons100 mL Graduated Cylinder6 Erlenmeyer flasks6 Rubber bands 6 BalloonsRulerProcedure: 1. Obtain 6 labeled Erlenmeyer flasks.2. Fill each flask accordingly: Bottle A -  5 mL sugar, 3 grams of dry yeast Bottle B - 10 mL sugar, 3 grams of dry yeast Bottle C - 15 mL sugar, 3 grams of dry yeast Bottle D - 5 mL sugar, 3 grams of dry yeast Bottle E - 3 grams of dry yeast Bottle F - 15 mL sugar 3. Fill all flasks except D with 100 mL of warm water.  Fill flask D with 100 mL of ice cold water. 4. Place a balloon over the top of each flask and tighten it with a rubber band. 5. Swirl flask to mix contents. Wait 20-30 minutes.6. Record observations in Table 1.7. Measure the width and height of the balloon (from the top of the flask to the top of the balloon) with a ruler, and record it in Table 1. 8. Graph the Sugar Quantity vs. Balloon Height in an X-Y Scatterplot. Insert DIGITAL scatterplot only.  Written graphs and/or pictures of written graphs will not be accepted. Table 1: Observations and Measurements of Balloon height in cm Flask Observations Height Width A 1st to rise 4.5inch 2inch B 3rd to rise 3.8inch 1.5inch C 2nd to rise 4.2inch 1.8inch D Did not rise 0 0 E Did not rise 0 0 F Did not rise 0 0 Conclusion:  Be sure to address the following:   How did your original rationale compare to the data collected?  If your rationale was incorrect, why do you think it did not produce the most CO2? Describe what happened in this reaction using the following terms: yeast, warm water, cold water, sugar, anaerobic respiration, and carbon dioxide. Compare what happened to each of the balloons for flasks A through F. Which flask had the most CO2 production? Least? How do you know? Be sure to describe WHY! There were four experimental flasks and two control flasks in this exercise.  Which flasks were the experimental and which were the control flasks?  Explain how each determination was made.

Biopsychology

Answer the questions below completely and fully. This requires a minimum of two substantive paragraphs for each answer with a minimum total of 300 words for the combined paragraphs (not including the references). Use learning resources and outside academic references (not Wikipedia!) to answer the questions completely. Support your answers with source credits (citations and references). Use APA formatting for all your work. Describe the recent finds on the “Nature-Nurture Controversy.” How do evolutionary theory (evolutionary biology and evolutionary psychology) and the study of genetics fit into this discussion? What are the implications for the biopsychologist? And finally, is there a controversy at all? Describe the process of action potential conduction and neurotransmission from one neuron to another, both electrically (including saltatory conduction) and chemically. Describe how a cell fires an action potential and be sure to address which structures are involved in neurotransmission. Discuss reuptake and enzymatic degradation (breakdown) in the context of the appropriate neurotransmitters. Trace in detail the structure and function of the visual system from the physical stimuli (light waves), to the structure of the eye and through the corresponding brain structures until it is processed as visual information. You will need to compare photoreceptors in darkness to photoreceptors receiving light and describe how light energy is transduced into neural signals. Describe how the trichromatic and opponent-process theory explain how light of different wavelengths is converted into color information. Discuss some of the methodological approaches that can be used to examine the influence of multiple genes on behavior.Then discuss what transgenic animals are and how they are produced. What is the medial forebrain bundle?Discuss the evidence for and against its involvement in reward.In addition, review the evidence showing that the brain’s dopamine pathways are critically involved in pleasure and reward. What is the monoamine theory of depression?What evidence supports this hypothesis as a cause of affective disorder?It generally takes 2-3 weeks of chronic treatment before an antidepressant begins to have a clinical benefit, yet the drug’s pharmacological effect (for example, its inhibition ofMOA, or reuptake) is immediate.What synaptic mechanisms may underlie this time lag? Critically evaluate the roles of the lateral hypothalamus and ventromedial hypothalamus in hunger and satiety. What other brain sites are known to be involved in eating behavior? Can this be explained in terms of a homeostatic model? What evidence shows that non- homeostatic mechanisms also contribute to feeding? Describe the brain structures and anatomical pathways that make up the extrapyramidal and pyramidal motor systems.What are the main functions of these two systems?What regions in the cerebral cortex are known to be involved in movement?How do these areas contribute to the production of motor behavior? Describe the dorsal and ventral streams. Describe two theories of their functional difference and the evidence on which each theory is based. Describe the main structures of the brain stem, the midbrain, and forebrain, including the basal ganglia, the limbic system and the cerebral cortex.What functions and behaviors are these regions known to control?27/05/202050psychology