Nursing Care Framework – 2019 – Version 1

NURSING CARE
FRAMEWORK
Nursing Care Contact Group
2019

MSF - Nursing Care Contact Group Page | 1

 Nursing Care Framework – 2019 – Version 1
INDEX

1. INTRODUCTION ......................................................................................................................................................... 3
1.1. Purpose of the framework ................................................................................................................................ 3
1.2. Common features of nursing globally ............................................................................................................... 3
1.3. The unique contribution of nurses ................................................................................................................... 3
1.4. International Council of Nurses Code of Ethics for Nurses and its definitions of nurse and nursing care ....... 4
1.5. The five main challenges facing nurses (and in particular MSF nurses) globally .............................................. 4
1.5.1. Pressure caused by current staff shortages and lack of resources ........................................................... 4
1.5.2. Poor quality and/or lack of education, training and professional development ...................................... 4
1.5.3. The undervaluing and restriction of the nursing contribution and denial of professional autonomy ..... 5
1.5.4. Difficulties with recruitment and retention .............................................................................................. 5
1.5.5. Lack of involvement in leadership ............................................................................................................ 5
1.6. Nursing in humanitarian settings ...................................................................................................................... 6
2. NURSING CARE FRAMEWORK ................................................................................................................................... 7
2.1. Four fundamental values characterizing nursing care in MSF .......................................................................... 7
2.1.1. Empathy .................................................................................................................................................... 7
2.1.2. Person-centred care .................................................................................................................................. 7
2.1.3. Safe, effective practice .............................................................................................................................. 7
2.1.4. Interdisciplinary approach ........................................................................................................................ 8
3. CLINICAL NURSING CARE ........................................................................................................................................ 11
1. Managing the patient journey from assessment through to discharge ............................................................. 11
2. Supporting the patient with human functioning ................................................................................................ 14
3. Supporting the patient through the diagnostic process ..................................................................................... 17
4. Supporting the patient through treatment ........................................................................................................ 18
4. MANAGEMENT and SUPERVISION .......................................................................................................................... 20
1. Clinical supervision and management ................................................................................................................ 20
2. Human resources and competencies management ........................................................................................... 20
3. Strategic management ........................................................................................................................................ 20
4. Resources management...................................................................................................................................... 20
5. References and notes.............................................................................................................................................. 21

MSF - Nursing Care Contact Group Page | 2

 Nursing Care Framework – 2019 – Version 1
1. INTRODUCTION
1.1. Purpose of the framework
In MSF we have over 8,000 nursing care providers, making them the majority of our healthcare workforce. A wide
range of staff fall into this category, which means different things in different places, but for the purposes of this
framework we refer to all nursing care providers as ‘nurses’. MSF nurses have nursing qualifications from over 80
countries, each with its own nursing curriculum and scope of practice. As a result, their scope of practice and the
skills they are expected to have can vary greatly. To address the challenges that can arise from this diversity, the MSF
Nursing Care Contact Group (NCCG) has created the Nursing Care Framework to:
1. set out the range of roles needed to provide nursing care in MSF and the increasingly complex competencies
required to fulfil them
2. define the skills, knowledge and competencies that all MSF nurses are expected to have, and the additional
skills that specific nursing roles must also have
3. act as a reference document for nurse managers e.g. use to evaluate and manage the introduction of new or
changing roles and responsibilities, develop job descriptions, plan a curriculum for training.
The framework is intended for:
 nurses and all members of the multidisciplinary clinical and management team
 training/education providers
 institution managers and leaders (including other departments, such as HR)
 external stakeholders (e.g. Ministries of Health, civil society groups, professional organisations and
governance boards).

1.2. Common features of nursing globally

 Nurses work across the entire continuum of care (from birth to death and from health to illness) and in all health
care settings (primary, secondary, community etc.). Everyone will see a nurse at some point in their life (1)(2)(3).
 Nurses are accessible. Nurses are frequently the first, and in some cases the only, health care professionals with
whom patients come into contact (1)(2).
 Nurses spend considerable time with their patients and the patients’ families. Nurses provide personal, intimate
care and ensure continuity of care throughout a period of illness or treatment (2)(4).
 Nurses work within a shared system of humanitarian and person-focused values. Nurses assist patients with
activities that they would perform unaided if they had the strength, will and/or knowledge (5). Nurses are not
perceived as being superior in status to patients, which puts them in a good position to provide person-centred
care and encourage self-management (6)
 Nurses are generally part of the local community and have a good understanding of local issues and culture,
which affect them and their families as well as their patients and their patients’ families. This cultural
competence and sensitivity is invaluable for MSF (1)(4).

1.3. The unique contribution of nurses

• Nurses undertake different roles in different circumstances, but globally they all have a combination of
knowledge, practical skills and values that makes them particularly well placed to meet both present and future
health care needs (7)(4).
• Other health care professions share some or all of these features. However, the nursing contribution is unique
because of its scale and the range of roles that nurses fulfil (4). This is as true within MSF as anywhere. Nurses
are the largest health care professional group that MSF employs and work in all MSF projects.
• This combination of large numbers, varied skills, cultural competency and intimate person-centred care, means
that MSF nurses are very well positioned to respond to the growing need for more person- and community-
centred care, and for a greater focus on health promotion and disease prevention, in line with MSF’s current
strategic ambitions.

Page 3 of 22
 Nursing Care Framework – 2019 – Version 1
1.4. International Council of Nurses Code of Ethics for Nurses and its definitions of nurse and nursing care
Nurses provide nursing care in accordance with the Code of Ethics for Nurses produced by the International Council
of Nurses (ICN). Nursing is a unique profession, with its own requirements, skills and responsibilities. Nursing is not a
list of basic tasks to be performed with kindness – it is a highly skilled job that requires comprehensive formal
education and intensive hands-on learning. MSF uses both the ICN Code of Ethics and its definitions of nurse and
nursing care.
“Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to
alleviate suffering. The need for nursing is universal. Inherent in nursing is a respect for human rights, including
cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful of and
unrestricted by considerations of age, creed, culture, disability or illness, gender, sexual orientation, nationality,
politics, race or social status. Nurses render health services to the individual, the family and the community and
coordinate their services with those of related groups.” (8)

“The nurse is a person who has completed a program of basic, generalized nursing education and is authorized by
the appropriate regulatory authority to practice nursing in his/her country. Basic nursing education is a formally
recognized program of study providing a broad and sound foundation in the behavioural, life, and nursing sciences for
the general practice of nursing, for a leadership role, and for post-basic education for specialty or advanced nursing
practice. The nurse is prepared and authorized to engage in the general scope of nursing practice, including the
promotion of health, prevention of illness, and care of physically ill, mentally ill, and disabled people of all ages and in
all health care and other community settings; to carry out health care teaching; to participate fully as a member of
the health care team; to supervise and train nursing and health care auxiliaries; and to be involved in research.” (9)

“Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and
communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the
care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping
health policy and in patient and health systems management, and education are also key nursing roles.” (9)

1.5. The five main challenges facing nurses (and in particular MSF nurses) globally
These challenges correspond to those identified by the WHO and those presented in the Triple Impact report (2)(4).

1.5.1. Pressure caused by current staff shortages and lack of resources

There is a global shortage of nurses (2)(10)(11)(12). This shortage is made worse by the uneven distribution of health
care services across and within countries, which often means that the people most in need do not have access to
services geographically close to them (2). This challenge is acutely felt by MSF, for example in South Sudan and the
Central African Republic. The current shortage of nurses is predicted to continue in many countries and the gap
between the numbers entering the profession and the predicted global need continues to widen - there are simply
not enough nurses being trained (4). Nurses also face additional pressure due to lack of resources and infrastructure,
for example poor-quality or missing equipment, poor routine maintenance and lack of medicines and other medical
supplies (7).

1.5.2. Poor quality and/or lack of education, training and professional development
Nurses need education and training before they start work, as well as opportunities for continuing professional
development once they have started, in order to enable them to deliver high-quality and compassionate care that is
appropriate to the context. However, access to such education, training and development is often limited. In
addition, there are shortcomings in much current nursing education and training, including a focus on areas with
little relevance to clinical practice, and courses being taught by non-nurses (4). There is a lack of clinical placement
options for student nurses and a lack of jobs for newly qualified nurses with effective supervision and support
systems in place to help them grow in confidence. These weaknesses in education, training and development reduce
the resilience of the health care system as a whole.

Page 4 of 22
 Nursing Care Framework – 2019 – Version 1
In addition, there is variation in the nursing skills, expertise and support needed in different contexts. In parts of
Africa – the continent with the lowest proportion of health workers to the population – there is a need to train
thousands more nurses in the practical skills that will enable them to deal with as wide a range of issues as possible –
effectively making them specialists in general nursing. Globally there is a growing need to train specialist nurses as
countries develop services for cancer and other non-communicable conditions. In rural areas where nurses work
independently, they need training to enable their scope of practice to be extended to include diagnostic elements
and prescribing (2)(7)(13)(4).

However MSF, like many other organizations, is still learning how best to transfer skills and develop clinical
competencies, how to supplement our traditional (classroom) training methodology with the mentoring and
coaching needed for sustained learning, and how to link the training we provide with the national education systems
in the countries where we work.

1.5.3. The undervaluing and restriction of the nursing contribution and denial of professional autonomy
In many countries, the role of the nurse remains undervalued and unrecognized; in several countries there is no
nursing council or equivalent (i.e. a regulatory, governing, or professional body) and/or no organization legally
representing the profession. This absence of legal frameworks that would support the role of nurses and their
participation in the planning and delivery of care creates significant obstacles for those trying to advocate for the
rights and duties of nurses (14)(4).

Contributing factors can include the dominance of the medical profession, which has high status and power and
controls much of the health care environment (15)(4). While in some countries the medical and nursing professions
interact positively, in other countries doctors make all the decisions around what nurses do, allowing them little
agency and considering them as merely “extra hands” for doctors. In some cases, this attitude actually inhibits the
development of nursing (4).

In comparison to the medical profession, nursing is generally perceived as a low-status profession, with low salaries,
poor working conditions and little investment. This low status of nursing is partly attributable gender, to the fact that
a majority of nurses are women, and women themselves have low status in many societies. Forms of care frequently
associated with women, such as hands-on intimate care and emotional support, are also globally undervalued (4).

Where it is relevant to our operations, MSF is working to overcome this challenge by creating nurse-led models of
care, pushing for an extended scope of practice and demonstrating the success of these approaches through
operational research (e.g. in sexual violence programmes, HIV, TB and NCD clinics). MSF is also working to
strengthen our recognition of nursing and nursing pride through the celebration of International Nurses Day, and by
speaking at international conferences to share our successes and challenges.

1.5.4. Difficulties with recruitment and retention

Too often nurses experience poor working conditions, unsafe and unsustainable workloads due to staff shortages,
and a lack of basic equipment and amenities. Such problems lead to poor morale and low job satisfaction, made
worse by factors already noted – including low pay, undervaluing of the nursing workforce and limited professional
development and career progression (4). Together, all these factors reduce nurses’ effectiveness and job
satisfaction, causing large numbers to leave the profession and making it hard to recruit replacements.

1.5.5. Lack of involvement in leadership

In many countries, nurse leaders are not involved enough in policy-making and decision-making locally, nationally
and internationally, even though their involvement is essential to improve patient care and service design (4). Newer
approaches to health care that embrace a greater degree of teamwork and the full engagement of patients,
caregivers and communities will need strong nursing leadership and a strong nursing voice (16). MSF has been
making progress in this area by introducing nurse leadership positions in our hospital management teams (for

Page 5 of 22
 Nursing Care Framework – 2019 – Version 1
example in Niger, Yemen, Afghanistan and the Democratic Republic of the Congo). However, the lack of access to
management training is still a barrier to effective nursing leadership. We have also created nurse advisor positions
within our headquarters (forming the Nursing Care Contact Group (NCCG)), although nurses are still under-
represented in MSF’s high-level clinical, executive, and governance positions.

1.6. Nursing in humanitarian settings

All the challenges discussed above are exacerbated in the humanitarian settings in which MSF provides nursing care.
Although each context we work in is different, one recurring issue, regardless of context, is that the needs that
confront us are often greater than the resources we have to meet those needs, making it impossible to deliver an
ideal level of nursing care. Most of the other challenges we face either follow from, or are at least made worse by,
this shortfall, and it is our locally recruited staff who carry most of this burden.

The settings that MSF works in are typically humanitarian settings – in other words situations characterized by large-
scale human suffering, whose alleviation requires a systematic response. Such situations range from chronic
problems resulting from socioeconomic circumstances, such as sexual and gender-based violence; through long-term
medical challenges such as those posed by neglected tropical diseases; to acute crises caused by conflicts or
disasters in which large numbers of people have been injured or displaced, or acute epidemics.

In conflict situations, the lack of security has a major impact on nursing care. As well as often being obliged to work
in damaged and potentially unsafe facilities, MSF nurses may have to provide nursing care within or close to active
conflict zones, risking death not only while at work but when travelling to and from work. Nurses therefore need to
take steps to ensure their own and their families’ safety, as well as that of their patients. Curfews make it difficult to
provide 24-hour care.

Interventions in disasters, whether natural or man-made, can be extremely challenging due to the scale of loss and
destruction and the chaotic, often frightening situation following the disaster. Affected areas and victims must be
reached quickly; expectations and needs are often very high and few resources may be available. MSF nurses are
often on the front line and technical and ethical dilemmas are a constant feature of these situations.

During epidemics and pandemics, in addition to their normal clinical and administrative activities nurses play a
broader role by virtue of their proximity to the populations that MSF is assisting. They take responsibility for mass
vaccination campaigns, health education activities, the setting up of care centres, epidemiological investigations and
community engagement activities to reduce public fear and stigma.

From the standpoint of the recognition of health as a human right (7) MSF nurses work hard every day to help
change the focus of health care from the disease to the person, and play a key part in transforming health care and
health systems to ensure that nobody is left without access to care. Nurses are often the only health care staff to
whom a person has access at critical moments. This is especially true for those living in rural areas. It is also
becoming increasingly true for people who become migrants in response to economic crises and climate change.

There are various contexts in which MSF nurses may be required to take on additional roles. This may result in nurses
working beyond the scope of their training or experience, for example treating types of wounds that they have not
encountered before or diseases they have studied only in theory. In contexts where there are high patient numbers,
nurses cannot devote as much time as normal to individual patients and have to work longer hours, despite physical
and emotional fatigue. When supply lines are cut, nurses must work with fewer resources, often necessitating rapid,
on-the-spot assessment and problem-solving, including making judgements about what compromises can be made to
nursing care with minimal impact on patient safety and wellbeing.

MSF nurses are often part of the communities they serve. However, the challenge in humanitarian settings is that
nurses may have to care for their own family members, friends or acquaintances. In conflict situations MSF nurses
may even be called upon to nurse perpetrators of violence, or members of hostile forces.
Page 6 of 22
 Nursing Care Framework – 2019 – Version 1
2. NURSING CARE FRAMEWORK
The NURSING CARE FRAMEWORK defines the range of skills, knowledge and competencies expected of those
providing nursing care in MSF. It identifies two main domains, clinical nursing care and supervision and managerial
activities, underpinned by four fundamental values characterizing nursing care in MSF.

The right part of the framework relates to clinical nursing care and represents the needs of patients along their care
pathway, with the related nursing care technical skills, knowledge and competencies. This list is broad and includes
all the activities likely to be undertaken in all the different types of health facility or project with their various levels
of care and specialities. The categories are based upon the Royal Marsden Manual of Nursing Procedures (17).

The left part of the framework relates to supervision and managerial activities and includes all possible levels, from
the supervision of a small unit or activity to the direction of a nursing department and participation in a hospital
management team.

2.1. Four fundamental values characterizing nursing care in MSF

The MSF NCCG defines four fundamental values which, although they are not exclusive to nurses, should
characterize nursing care within all MSF projects: empathy; person-centred care; safe, effective practice; and an
interdisciplinary approach.

2.1.1. Empathy
The nursing profession is rooted in empathy – the ability to understand and share the feelings of others. The skill of
being able to listen to and communicate with patients and relatives requires emotional intelligence and compassion.
It is a core skill required of MSF nurses and it is essential to providing emotional support and upholding dignity. It is
by means of empathy that nurses engage with and empower patients. One definition of nursing says that the nurse’s
function is to "assist the individual, sick or well, in the performance of those activities contributing to health or
recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge"
(5). Nursing practice embraces the conviction that empowering our patients will enable them to participate in their
own health and wellbeing, so increasing the effectiveness of their treatment and improving their quality of life.

2.1.2. Person-centred care

Person-centred care means putting patients and their families at the centre of health care decisions, recognizing
them as experts in their own wellbeing, and enabling them to work alongside health professionals to achieve the
best outcomes (18)(19). Such an approach to care encompasses both attitudes and actions, and is grounded in a
sense of empathy. The underlying philosophy of person-centred care is one of respect for patients and their values,
consideration of their preferences and expressed needs, and an emphasis on acting with, rather than doing to,
patients in order to help them achieve their goals (20). Modern nursing training instils a holistic and person-centred
philosophy and as a result nurses are well placed to ensure person-centred care and to advocate on behalf of
patients (16)(6).

2.1.3. Safe, effective practice

Safe practice is the cornerstone of high-quality care. As frontline health care workers, nurses are in intimate contact
with patients and caregivers. All health care comes with some degree of risk, and in humanitarian contexts the risk of
adverse events may be higher than usual due to the poor state of infrastructure and equipment, the unreliable
supply and quality of medicines, poor staffing ratios and lack of the necessary specialist skills (21). Such heightened
risk makes the role of nurses all the more crucial in creating a culture of safety and open learning in order to ensure
safe care. MSF nurses should therefore be empowered to contribute actively to these goals through supportive
supervision, encouraging active participation in the monitoring of safety structures and processes, and ensuring
nurses can report deficiencies or shortcomings in practice without fear.

Page 7 of 22
 Nursing Care Framework – 2019 – Version 1
Effective nursing is strongly dependent upon the promotion of a scientific approach to nursing care. Evidence-based
practice should be the foundation of any nursing care activity; MSF nurses should be supported to deliver evidence-
based care through post-employment training and coaching.

2.1.4. Interdisciplinary approach

As the needs of MSF’s patients and the care we deliver to them grow steadily more complex across a wider range of
settings, a single profession alone cannot provide the holistic care that patients need. The need to coordinate care
across multiple disciplines to ensure the best possible outcomes is increasingly important. An interdisciplinary
approach relies on working collaboratively with both patients and health professionals from different disciplines. The
most effective interdisciplinary teams share responsibilities and promote role interdependence, while respecting
their individual members’ experience and autonomy. MSF nurses coordinate care, ensuring continuity within and
between services (22)(23)(24)(25). It is therefore essential that they take a leadership role in the enhancing of
interdisciplinary collaboration and coordination, the breaking down of professional silos and the development of
well-functioning teams (26). MSF nurses should provide nursing care in partnership with other health professionals,
learning about and sharing expertise with other disciplines. As a result, they will enrich their own practice and
provide better care for their patients.

Page 8 of 22
Nursing Care Framework – 2019 – Version 1

Page 9 of 22
Nursing Care Framework – 2019 – Version 1

Page 10 of 22
 Nursing Care Framework – 2019 – Version 1
3. CLINICAL NURSING CARE
1. Managing the patient journey from assessment through to discharge
1.1. Admission An integral part of patient care and the first step in the process of individualized nursing
evaluation care. Provides information that is critical to the development of an accurate nursing care
plan.
a. Triage
 Each OC advocates for a different triage system. Please refer to your OCs
preferred triage system.
 ETAT
 South Africa triage system
b. Complete nursing assessment of the patients
 Vital Signs
- Assessment of level of consciousness: AVPU
 Assessment of respiration: respiratory distress, respiratory
rate
 Assessment of oxygen saturation
 Assessment of capillary refill time
 Assessment of heart rate (pulse)
 Assessment of blood pressure
 Assessment of urine output
 Assessment of body temperature
 Assessment of pain
 Additional patient assessment
- Assessment of anthropometric measures
 Weight
 Height
 Head circumference
- Assessment of general appearance (pale, flushed, lethargic, active,
agitated, calm, compliant, combative, posture and movement)
- Assessment of skin and hair (colour, turgor, lesions, bruising, wounds,
pressure injuries)
- Assessment of nutritional status
 MUAC
 Z-score
 BMI
 Oedema
 Perform and interpret the appetite test
 Advanced patient assessment
- Neurological
 Glasgow Coma Scale
 Assessing motor function
 Assessing pupillary response
 Sensory function
- Respiratory
 Respiratory pattern
 Respiratory sounds
 Peak flow
- Cardiovascular
 Haemorrhages (venous vs arterial, estimation of severity,
etc..)
 EKG
 Shock
- Gastrointestinal

Page 11 of 22
 Nursing Care Framework – 2019 – Version 1
 Abdominal/bowel sounds
 Ingestion (appetite, nausea, dysphagia, sore mouths, etc..)
 Increased nutritional losses (vomiting, diarrhoea, ascites,
fistula, etc..)
- Metabolic
 Glycaemia
- Orthopaedic
 Peripheral circulation
 Range of motion
c. Document filings in a systematic way
- Patient admission forms
- Hospital registers
1.2. Coordination of the The nurse, due to the proximity to patients and their families, is the health care
care professional who will communicate most frequently with patients and has the best
insight into a patient's progress. Therefore nurses have the duty of oversee the patient's
delivery of care, often taking lead, and are responsible for sharing information within
the multi-disciplinary team (during the medical round, during the hand over between
shifts, during transfer between units or outside referral). (22)(23)(24)(19)
Nurses are also responsible of communicating correctly with patient's family or next of
kin and updating them on patient's care as appropriate. It is necessary to take their
needs and preferences into consideration during the care team decision process.
a. Continuity of care
 Transfer ward, handover, admission, communications.
b. Nursing care tools
 Nursing assessment form
 Nursing care plan
 Nursing observations
c. Patient documentation (list to be refined over time)
 Medication chart
 Vital sign chart
 Nursing admission form
 Fluid balance chart
 Blood transfusion chart
 Rehydration chart
 Wound care chart
 Nursing notes
1.3. Patient advocacy Patient advocacy is integral to nursing. Nurses have a responsibility to advocate for the
rights, values, wellbeing and best interests of patients.(27)(28)(22)
Patient advocacy includes:
 (with the team) ensure the patient has understood their diagnosis, prognosis
and treatment options by providing clear and complete information.
 To ensure that the patient is at the centre of their care
 To ensure that the patient (and the family) are involved in the decision-making
process
 To ensure there is transparency with care delivery.
 To represent the patient's best interests at times when they are unable to
communicate for themselves (e.g. when unconscious).
 To ensure patient dignity at times, especially when they are unable to do so
for themselves.
 Helping patients and families form relationships with other health care
professionals and to cope with the complexities of health care systems.

Page 12 of 22
 Nursing Care Framework – 2019 – Version 1
1.4. Patient/family Nurses’ patient education is important for building patients’ knowledge, understanding,
education and and preparedness for self-management (Bergh et al>, 2015). Nurses are important
support of self- professionals for the provision of patient education and are expected to incorporate
management patient teaching into all aspects of their practice (30)(31)
Patient/family education and support of self-management includes:
 Informing patients (giving information about a clinical procedure)
 Help the individual gain control over their health and participate in their own
health decision making.
 Promote and encourage self-management, enabling patients and families to
function independently and achieve the highest quality of life.
 Provide patient and family with all information necessary to enable self-care
 Give information on unit/hospital functioning to patient and family
1.5. Patient safety Nurses are a constant presence at the bedside and regularly interact with physicians,
pharmacists, families, and all other members of the health care team. Of all the
members of the health care team, nurses therefore play a critically important role in
ensuring patient safety by monitoring patients for clinical deterioration, detecting
errors and near misses, understanding care processes and weaknesses inherent in
some systems. (32)(33)(34)
a. Patient safety
 Patient identification
 Risk Identification assessments
- Pressure ulcers risk assessment and prevention efforts
- Patient falls risk assessment and mitigation
 Safe medication practices
 Identification and reporting of medical incidents and active participation in
risk mitigation
 Empowerment of patients and caregivers to be engaged in their care and to
ask questions or report concerns with safety

b. Infection prevention and control (35)

 Standard precautions (36) are standard measures to reduce the risk of
transmission of blood borne and other pathogens from both recognized and
unrecognized sources. Specific activities include:
o Hand hygiene
o cleaning and disinfection of surfaces (environmental cleaning)
o safe reprocessing of reusable medical devices and equipment
o prevention of accidental exposure to bodily fluids (including needle
stick injuries)
o use of personal protective equipment (PPE)
o handling of patient equipment and linen
o waste management
o respiratory hygiene
o injection safety
 Care of patient on transmission-based precautions (contact, droplet, airborne,
strict)
 Pre-cleaning of critical and non-critical reusable medical devices (endoscopes,
surgical sets, etc.) prior to safe reprocessing in sterilization department
 Educating patient/caregivers on infection prevention and control concept as
applicable (hand hygiene, PPE for transmission-based precautions, respiratory
hygiene, etc.)
 Safe nursing care techniques including but not limited to:
o Aseptic technique (including injection practices, urinary
catheterization, dressings, etc.)

Page 13 of 22
 Nursing Care Framework – 2019 – Version 1
 Waste management (sharps, biohazardous and biological waste, domestic
waste and special waste, etc.)
1.6. Discharge planning Discharging patients can be complex and it is the nurse’s responsibility to ensure it is
done comprehensively. Patients must be included in the discharge-planning process.
Discharge planning includes:
 Ensuring the patient returns to the community with the appropriate care to
support them at home.
 Ensuring all nursing and patient concerns are raised and addressed prior to
discharge
 Ensuring any follow-up is organized and the patient is aware of the plan of
action
 That discharge medications are issued and explained to patient, and ensure
the patient has understood (patient education)

2. Supporting the patient with human functioning

Relates to support a patient may require with normal human functioning.
2.1. Communication Good communication between nurses and patients is essential for the successful
outcome of individualized nursing care of each patient (37)
 Identify through the verbal or non-verbal discourse the necessity of a care
intervention
 Anger, aggression and violence management
 Delirium / dementia
 Communicating with a person who is blind or partially sighted
 Communicating with a person who is deaf or hard of hearing
2.2. Respiratory care a. Respiratory therapy:
 Oxygen therapy
- Humidification for oxygen therapy
- Nasal cannula
- Mask
- Non-rebreathing mask
- High-flow oxygen therapy
- Continuous positive airway pressure
- Ventilated patient
 Suction
- Nasal suctioning
- Oropharyngeal suctioning
- Tracheobronchial suction
b. Chest drain:
- Assistance during insertion
- Priming ambulatory chest drain bag
- Changing the bottle
- Management of suction
- Assisting during removal
 Assisting during pleural tape
c. Tracheostomy care
 General and emergency management
 Dressing and fixation change
 Suctioning
 Inner cannula change/cleaning
d. Emergency respiratory care
- Emergency recovery position (lateral)
- Use of oral airway
- Assisting placement of oropharyngeal airway (LMA)
Page 14 of 22
 Nursing Care Framework – 2019 – Version 1
- Assisting intubation
- Manual ventilation with self-inflating bag (ambu bag, bag valve mask
BVM)
2.3. Circulation and a. Transfusion of blood and blood components:
blood transfusion  Blood product request
 Blood sampling: pre-transfusion
 Blood components: collection and delivery to the clinical area
 Bedside compatibility test pre transfusion
 Blood component administration and patient monitoring
b. Emergency circulatory care
 Management of haemorrhages:
- Emergency control of haemorrhages
- Assessment (venous vs arterial, estimation of severity, etc…)
 Cardiopulmonary resuscitation
 Use of defibrillator
- Manual
- Automated External Defibrillator (AED)
2.4. Nutrition and fluid a. Fluid balance
balance  Fluid input measurement
 Fluid output measurement
b. Nutrition
 Normal oral feeding
 Provision of oral nutritional support:
- Therapeutic feeding (special milk, RTUF)
 Nutritional management of patients with dysphagia
 EnFit gastric/duodenal tube
- Insertion
- Care
- Management of complications
- Administration of food
- Administration of medication
- Removal
c. Abdominal ascites
 Assisting therapeutic paracentesis (removal of ascetic fluid)
 Care and monitoring of drainage
2.5. Elimination a. Care of a patient who is vomiting
 Positioning
 Hygiene
b. Nasogastric drainage tube
 Insertion
 Care
 Management of complications
 Removal
c. Assisting the patient with elimination
 Slipper bedpan and urinal use
 Commode chair use
 Nappy
d. Assisting the patient with urinary elimination
 Urinary incontinence: penile sheath application
 Urinary catheterization (male and female)
- Insertion
 Indwelling
 Intermittent
- Care
Page 15 of 22
 Nursing Care Framework – 2019 – Version 1
- Management of complications
- Removal
 Suprapubic catheterization
- Care
- Management of complications
 Bladder irrigation
 Urinary catheter bag
- Emptying
- Changing
e. Assisting the patient with intestinal elimination
 Care of the patient with diarrhoea
 Care of the patient with constipation
 Enema administration
 Digital rectal examination
 Digital removal of faeces
 Stoma
- Care
- Management of complications
2.6. Moving and a. Moving and positioning: general principles
positioning  Prevention of falls
 Prevention of pressure ulcers
 Positioning the patient:
- Supine;
- Sitting in bed;
- Side-lying;
- Lying down to sitting up;
- In a chair/wheelchair
 Assisting the patient to move from sitting to standing
 Positioning to:
- Maximize ventilation/perfusion matching;
- Minimize the work of breathing;
- Maximize the drainage of secretions
b. Moving and positioning patients in special conditions
 Unconscious patient or the patient with an artificial airway in supine and in
side-lying
 Patient with respiratory compromise
 Neurological patient with tonal problems
 Pre-operative and post-operative
- Early mobilization of the patient in bed
 Patient with actual or suspected spinal cord compression or spinal cord injury
c. Assisting the patient to walk
 Use of crutches
 Walking frame
2.7. Patient comfort a. Personal hygiene
and end-of-life care  Bed bathing a patient;
 Washing a patient’s hair in bed;
 Care of the menstruating patient
b. Specific hygiene
 Eye care
- Eye swabbing
- Eye irrigation
- Artificial eye care: insertion and removal
 Ear care
 Mouth care
Page 16 of 22
 Nursing Care Framework – 2019 – Version 1
c. Pain management
 Pain evaluation
 Non-pharmacological pain management
- Position
- Comfort
- Psychological support
 Pharmacological pain management
 Monitoring and assistance for
- Epidural and intrathecal analgesia
- Regional analgesia (local anaesthetic nerve blocks and infusions)
d. Temperature regulation
 Hypothermia
- Prevention
- Care
 Hyperthermia
- Prevention
- Care
e. Care of dying patient
 Palliative care
 End-of-life
 Personal care after death

3. Supporting the patient through the diagnostic process

3.1. Diagnostic tests a. Blood sampling
 Capillary blood sampling
 Blood sampling through venepuncture
 Collection of a blood culture through venepuncture
b. Cerebrospinal fluid obtained by lumbar puncture
 Assisting in the execution of the lumbar puncture
 Management of the sample
c. Specimen collection
 Swab sampling: ear; eye; nose; penis; rectum; skin; throat; vagina; wound
 Urine sampling: midstream specimen of urine (male/female); catheter
specimen of urine (CSU)
 Faecal sampling
 Sputum sampling
 Gastric aspirate
d. Radiological and imagery investigations:
 Radiological safety awareness (for patient, caregiver and nurse)
 Patient preparation
e. Point-of-care tests:
 Urinalysis: reagent strip procedure
 Blood glucose monitoring
 Blood haemoglobin measurement (HemoCue®)
 Rapid Diagnostic Tests (RDTs)
f. Diagnostic process
 Filling of examinations request forms
 Management of sample/patient transport
 Results filing

Page 17 of 22
 Nursing Care Framework – 2019 – Version 1
4. Supporting the patient through treatment
It includes the procedures related to specific types of treatment or therapies the patient is receiving.
4.1. Medicines a. Safe medication practices
management  Safe medication use process
 Safe use of oral medicines
 Safe use of injectable medicines
 SALADs: ‘Sound– Alike and Look – Alike drugs
 Cytotoxic medicines
b. Oral drugs
 Preparation and administration of oral drugs
- Tablets
- Syrup
 Preparation and administration of medication through nasogastric tube
c. Ophthalmic drugs for external use
 Preparation and administration of ophthalmic drops
 Preparation and administration of ophthalmic ointment
d. Drugs for external use
 Preparation and administration of topical drugs
 Preparation and administration of transdermal drugs
 Preparation and administration of rectal drugs (suppository)
 Preparation and administration of vaginal drugs
 Preparation and administration of nasal drugs (nasal drops)
e. Respiratory drugs
 Preparation and administration of pulmonary drugs by inhalation
- Metered-dose inhaler
- Nebulizer
- Dry powder inhaler
f. Injectable drugs
 Preparation of injectable drugs:
- Ampoule
- Vials
 Preparation and administration of intradermal injection
 Preparation and administration of subcutaneous injection
 Preparation and administration of intramuscular injection
 Preparation and administration of intravenous drugs
g. Infusions
 Preparation and administration of infused drugs and fluids
- Paediatric infusion set
- Adult infusion set
- Drip counter
- Syringe pump
- Infusion pump
- Drip calculation and counting
h. Vaccines
i. Preparation and administration of intraosseous drugs and fluids
j. Preparation and administration of controlled drugs
k. Long acting reversible implants
4.2. Perioperative care a. Pre-operative care
 Patient information and education
 Consent
 Physical pre-operative preparation
 Pre-operative theatre checklist
b. Intra-operative care
Page 18 of 22
 Nursing Care Framework – 2019 – Version 1
 Caring for the patient in the pre-operative room
 Operating theatre procedure: maintaining the safety of a patient while
undergoing surgery
 Recovery room
- Handover recovery room unit: scrub nurse to recovery nurse
- Safe management of the patient in the recovery room
c. Post-operative care
 Post-operative observations
 Fluid balance monitoring
 Surgical drain management
 Urinary output and catheter management
 Bowel function monitoring
 Dressing of surgical site
 Nutrition monitoring and management
 Post-operative pain management
 Moving and positioning of immobile patients and early mobilization
 Ongoing care on discharge
4.3. Vascular access a. IV peripheral catheter
devices: insertion  Insertion
and management  Maintenance and monitoring
 Early identification of complications
 Assessment of patency
 Infiltration and extravasation management
 Removal of PIV
b. Intraosseous needle:
 Assistance during insertion
 Fixation and maintenance
 Removal
c. Peripheral Inserted Central Catheter (PICC)
 Insertion
 Manipulation and maintenance
 Early identification of complications and management
d. Central Venous Catheter (CVC)
 Assistance during insertion
 Manipulation and maintenance
 Early identification of complications and management
4.4. Wound care a. Care of patient with wound
 Preparation
 Patient assessment
 Wound assessment
 Cleansing
 Disinfection
 Dressing and fixation
 Post-care
b. Specific wound care
 Neonates
 Severe malnourished children
 External fixators and traction pin site
 Drainages
 Burns
 Abscess
 Suture removal
c. Negative Pressure Wound treatment
Page 19 of 22
 Nursing Care Framework – 2019 – Version 1
4.5. Specialized a. Help the patient to use support devices
orthopaedic - Cane,
care/treatment - Crutch,
- Cervical collar,
- Sling
b. Applying plaster casts
c. Care for a patient with a cast
- Positioning
- Monitoring
- Identification of complications
d. Care for a patient with tractions
- Positioning
- Monitoring and pressure sore prevention
- Identification of complications
e. Mobilization and assisting the physiotherapist

4. MANAGEMENT and SUPERVISION

1. Clinical supervision and management
Organization of care activities
Continuity of care and clinical
pathway
Patient documentation
Monitoring and evaluation of
quality and safety in nursing care
Handover process
2. Human resources and competencies management
Workload & workforce calculation
HR administrative role
Team meetings
Continuous professional
development
Evaluation
3. Strategic management
Mission – Vision - Values
Leadership
Data management
Knowledge management
Information management
Research
Advocacy
Deontology
Legal aspect Implementing the legal/mandate of the country…..
4. Resources management
Pharmacy – Supply
Biomed
Facilities
Supportive services
Ancillary service
Financial

Page 20 of 22
 Nursing Care Framework – 2019 – Version 1
5. References and notes
1. WHO. Nursing and midwifery key facts [Internet]. WHO. World Health Organization; 2018 [cited 2019 Apr 11].
Available from: https://www.who.int/mediacentre/factsheets/nursing-midwifery/en/
2. WHO. The Global Strategic Directions for Strengthening Nursing and Midwifery 2016-2020. WHO. World
Health Organization; 2016.
3. ICN. Nursing Care Continuum Framework and Competencies. 2008.
4. APPG. Triple Impact of Nursing [Internet]. APPG on Global Health. 2016. Available from:
http://www.appg.globalhealth.org.uk/
5. Henderson V. The Nature of Nursing: A Definition and its Implications for Practice, Research, and Education.
New York: Macmillan Publishing.; 1966.
6. WHO. “Everybody’s Business”: Strengthening Health Systems to improve health outcomes–WHO’s
Framework for Action. 2007.
7. ICN. HEALTH IS A HUMAN RIGHT. ACCESS, INVESTMENT AND ECONOMIC GROWTH. 2018.
8. ICN. ICN Code of Ethics for Nurses [Internet]. 2012 [cited 2019 Apr 11]. Available from:
http://www.old.icn.ch/who-we-are/code-of-ethics-for-nurses/
9. ICN. ICN Definition of Nursing and Nurse [Internet]. 2002 [cited 2019 Apr 11]. Available from:
http://www.old.icn.ch/who-we-are/icn-definition-of-nursing/
10. WHO. DRAFT 1.0 submitted to the Executive Board (138th Session): Global strategy on human resources for
health: Workforce 2030. 2016.
11. Campbell J DG, Buchan J, Pozo-Martin F, Guerra Arias M, Leone C, Siyam A CG. A universal truth: no health
without a workforce. Global Health Workforce Alliance and World Health Organization. 2013.
12. Deloitte. Global Health care outlook: Common goals, competing priorities. 2015.
13. OECD. Health at a Glance 2015: OECD Indicators [Internet]. 2015. Available from:
dx.doi.org/10.1787/health_glance-2015-en
14. Delamaire, M. Lafortune G. “Nurses in Advanced Roles: A Description and Evaluation of Experiences in 12
Developed Countries” [Internet]. 2010. Available from: http://dx.doi.org/10.1787/5kmbrcfms5g7-en.
15. WHO. WHO Expert Committee on Nursing 5th Report. WHO Technical Report Series No 347 [Internet]. 1966.
Available from: https://apps.who.int/iris/handle/10665/38190
16. ICN. Health is a human right – ICN Voice to Lead [Internet]. [cited 2019 Mar 13]. Available from:
https://2018.icnvoicetolead.com/health-is-a-human-right/
17. Dougherty L, Lister S. The Royal Marsden Manual of Nursing Procedures [Internet]. Ninth Edit. 2015. Available
from: http://www.royalmarsdenmanual.com/productinfo/
18. London H innovation network S. What is person-centred care and why is it important?
19. NMC. Standards of proficiency for registered nurses [Internet]. 2018. Available from:
https://www.nmc.org.uk/standards/standards-for-nurses/standards-of-proficiency-for-registered-nurses/
20. Gurría A. People at the Centre: The Future of Health–opening remarks at 2017 OECD High- Level Policy
Forum. In 2017. Available from: http://www.oecd.org/about/ secretary-general/people-at-the-centre-
thefuture- of-health-opening-remarks.htm.
21. WHO. Patient Safety: Making health care safer. 2017.
22. ANA. Care Coordination and the Essential Role of Nurses | American Nurses Association (ANA) [Internet].
[cited 2019 Apr 11]. Available from: https://www.nursingworld.org/practice-policy/health-policy/care-
coordination/
23. AHRQ. What is Care Coordination? [Internet]. [cited 2019 Apr 11]. Available from:
https://www.ahrq.gov/professionals/prevention-chronic-
care/improve/coordination/atlas2014/chapter2.html#fig1
24. Scholz, J., Minaudo J. Registered Nurse Care Coordination: Creating a Preferred Future for Older Adults with
Multimorbidity. OJIN Online J Issues Nurs [Internet]. 2015;20(3). Available from:
http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/
Vol-20-2015/No3-Sept-2015/Registered-Nurse-Care-Coordination.html
25. Ellis, J. Hartley C. Managing and Coordinating Nursing Care. 2005.
26. RCN. The nursing role in integrated care models | Royal College of Nursing [Internet]. [cited 2019 Apr 11].
Available from: https://www.rcn.org.uk/about-us/policy-briefings/pol-0214
27. Choi PP. Patient advocacy: the role of the nurse. Nurs Stand [Internet]. 2015 Jun 10 [cited 2019 Apr
11];29(41):52–8. Available from: http://journals.rcni.com/doi/10.7748/ns.29.41.52.e9772
28. Bu X, Jezewski MA. Developing a mid-range theory of patient advocacy through concept analysis. J Adv Nurs
Page 21 of 22
 Nursing Care Framework – 2019 – Version 1
[Internet]. 2007 Jan 1 [cited 2019 May 24];57(1):101–10. Available from:
http://doi.wiley.com/10.1111/j.1365-2648.2006.04096.x
29. Bergh A-L, Friberg F, Persson E, Dahlborg-Lyckhage E. Registered Nurses’ Patient Education in Everyday
Primary Care Practice: Managers’ Discourses. Glob Qual Nurs Res [Internet]. 2015 [cited 2019 Mar
23];2:2333393615599168. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28462314
30. Virtanen H, Leino-Kilpi H, Salanterä S. Empowering discourse in patient education. Patient Educ Couns
[Internet]. 2007 May 1 [cited 2019 Mar 23];66(2):140–6. Available from:
https://www.sciencedirect.com/science/article/pii/S0738399107000043?via%3Dihub
31. TOMEY AM. Nursing leadership and management effects work environments. J Nurs Manag [Internet]. 2009
Jan [cited 2019 Mar 23];17(1):15–25. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19166518
32. Network PS. Nursing and Patient Safety [Internet]. [cited 2019 Mar 23]. Available from:
https://psnet.ahrq.gov/primers/primer/22/Nursing-and-Patient-Safety
33. MSF. Quality Improvement: A systematic, field driven approach. 2017.
34. ICN. Patient Safety Position Statement [Internet]. 2012. Available from: https://www.icn.ch/nursing-
policy/icn-strategic-priorities/patient-safety
35. MSF. IPC Policy and strategic framework. 2017.
36. WHO | Standard precautions in health care. WHO [Internet]. 2015 [cited 2019 Apr 11]; Available from:
https://www.who.int/csr/resources/publications/standardprecautions/en/
37. Kourkouta L, Papathanasiou I V. Communication in nursing practice. Mater Sociomed [Internet]. 2014 Feb
[cited 2019 Mar 23];26(1):65–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24757408

Version 0.1 No previous document. Outline drafted by NCCG in 2017

Version 0.2 Includes introduction drafted by Vicky, feedback from USA board nurse Pat
Version 0.3 Vicky included edits from NCCG (discussed at meeting September 2018)
Version 0.4 Intro and competencies list edited by Andrea. Shared with OCB board nurse for feedback.
Version 0.5 Includes feedbacks from Anneli (OCB board nurse) + comments from NCCG members (December 2018)
Version 0.6 NCCG edits included by Vicky. 2 pages sent to editor. (Jan/Feb 2019)
Version 0.7 Includes editor comments, continued NCCG additions by Vicky, revisions from Anna QA (March 2019) and
NCCG decisions (April 2019)
Version 0.8 Including NCCG decisions and editor comments (May 2019)
Version 0.9 Includes editor amendments (May 2019) and final NCCG input
Version 1 Current document

Page 22 of 22