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The Role of Nursing Theory in Standards of Practice: A Canadian Perspective

Standards of practice serve a wide variety of purposes, including providing a guide to the knowledge, skills, judgment, and attitudes that are needed by nurses to practice safely. Standards describe what each nurse is accountable and responsible for in practice; they interpret nursing’s scope of practice to the public and other healthcare professionals; and they represent performance criteria against which nurses may be compared by consumers, employers, colleagues, and themselves. Standards of practice established by the profession itself are viewed as one of the keys to self-regulation. The following discussion explores the role nursing theory has played in the development of standards of practice in the province of Ontario, Canada. The College of Nurses of Ontario (CNO) is the regulatory body for nursing in Ontario. Nursing in Canada has a long history of self-regulation and Ontario is no exception. The regulatory authority is delegated by the government and is set out in the provincial Nursing Act and the Regulated Health Professions Act. Nursing regulation in Ontario is somewhat unique in Canada insofar as the College regulates both Registered Nurses (RNs) and Registered Practical Nurses (RPNs) under the same Nursing Act. In addition, CNO does not function as the professional association for nurses, because RNs and RPNs are represented by their own professional associations. Current College membership is approximately 140,000 nurses throughout the province. This includes about 106,000 RNs and 33,800 RPNs. At CNO, nursing is considered one profession with two categories of practitioner. The core purpose of regulation is protection of the public. The CNO’s mission statement was revised in 1999 to acknowledge that public protection can only be accomplished through effective self-regulation. Our mission is to protect the public’s right to quality nursing services by providing leadership to the nursing profession in self-regulation. The CNO views self-regulation as requiring open, accessible, and equitable processes to bring about safe, effective, and ethical nursing care in Ontario. There are many elements of effective self-regulation, including establishing entry to practice requirements, registering competent practitioners, ensuring competence in ongoing practice, dealing with complaints about nursing practice, and identifying and establishing standards of practice. Ontario’s legislation specifically requires the regulatory College to develop, establish, and maintain programs and standards of practice to assure the quality of the practice of the profession and standards of knowledge and skill, to promote the continuing competence among members of the profession. From a regulatory perspective, standards are necessary to carry out the College’s responsibilities. The CNO uses the term standard of practice very broadly to refer to provincial legislation, regulations, standards, policies, and guidelines that establish the CNO’s expectations in relation to member practice and conduct. When looking back at the standards of practice produced by the College over the years, it is clear that standards have evolved and changed significantly, reflecting the growth and evolution of the nursing profession. The expansion of nursing’s unique body of knowledge has informed and influenced the content and focus of standards of practice. The most striking change is the shift from standards that identify minimum expectations for practice and focus on the “tasks” of nursing practice to standards that emphasize professional responsibilities and decision-making based on nursing knowledge. In 1976, the first Ontario Standards of Nursing Practice for Registered Nurses and Registered Nursing Assistants (as RPNs were then called) were developed by the CNO. These early standards identified minimum expectations for practice and provided an early introduction to standards that used a decision-making framework. In response to member and employer demand, revisions to these standards focused heavily on the addition of skill lists identifying basic and added nursing skills. In 1985, in an attempt to remove the focus from skills, the CNO circulated a discussion paper proposing revised standards of practice based on the recognition that nursing was changing from a taskor activity-oriented vocation to a goal-directed profession with increasing recognition of nursing as a field of study as well as an occupation. The discussion paper provided information about the development of nursing science and the concept of theory-based practice and was followed by the circulation of The Proposed Revised Standards and Levels of Nursing Practice (CNO, 1988). These proposed standards introduced the use of a conceptual framework to guide nursing decisions and actions. The underlying assumptive base for the proposed standards acknowledged the role that nursing theoretical frameworks or models play in guiding nursing practice. The College adopted the concept of “theoretical pluralism,” which is an acknowledgment and acceptance of the variations in nursing theories or frameworks (Dickoff & James, 1984). In considering the two alternatives, the acceptance of theoretical pluralism or the 260 Nursing Science Quarterly, 13:3, July 2000