Download File - Deborah Jansen van Galen, RN, BSN, CMSRN

Running head: TRANSITION
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Nurse Transition: BSN to MSN
Deborah A. Jansen van Galen, RN, BSN, CMSRN
Ferris State University
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Abstract
This paper will review an RN, BSN’s scope of practice in medical/surgical/oncology inpatient
units and the development of a plan to transition into an advanced practice nurse role in clinical
education. The knowledge, skills and attitudes of current practice are reviewed and reflected
upon. Current philosophy as guided by the four nursing metaparadigm concepts is discussed. The
importance of nursing theory and its clinical application is also examined.
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Nurse Transition: BSN to MSN
The American Nurses Association (ANA) has defined nursing and provided the scope
and standards to which nurses are expected to practice by. The nursing process reflects the
standards of practice in combination with standards of professional performance (ANA, 2010).
The Scope and Standards of Practice: Nursing (2010) describes nursing and gives a frame of
reference for nursing competence. The metaparadigm concepts of person, health, environment
and nurse are used to explain the philosophy of nursing. Nursing theory and its implication in
current clinical practice is reviewed. The purpose of this paper is to reflect on my current
practice as an RN, BSN and plan my transition to an advanced practice nurse within the clinical
education realm.
Current Practice
In the three years since graduating with a Bachelors of Science in Nursing (BSN) degree,
not only have I grown as a nurse, I have grown as a person. Working on two
medical/surgical/oncology units has helped develop my knowledge, skills and attitudes that were
taught during school. I have gained perspectives from both a small and a large hospital setting,
unionized and non-unionized and under several managers all with varying management styles.
On a daily basis I use the nursing process, “assessment, diagnosis and identification of outcomes,
planning, implementation, and finally evaluation” (ANA, 2010. p 3), to guide my patient care. I
care for cancer patients from diagnostic testing through chemotherapy, radiation and surgery, to
recovery or comfort care. My general medical and surgical patients come with different needs
and fears. Many post operative patients are unaware of the complications from not ambulating
early, using their incentive spirometer and using narcotics. I assist with explaining treatments
and comfort measures as well as hospice care to patients and families. I answer questions about
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medications and address end-of-life issues when the time comes. I am a resource available to
educate and support patients, family members and peers.
Knowledge
The core content of nursing school has a general medical and surgical focus. Body
systems are explored, major disease processes are reviewed and appropriate nursing diagnoses
are applied. It is crucial that nurses keep the fundamentals while incorporating the most recent
research. One driving force of nursing care today is evidence based practice (EBP). Using the
latest research studies to help guide daily nursing practice will lead to improved patient outcomes
(Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2007. p 5). It is also important that nurses
concentrate on the current injury or illness that caused the hospitalization without disregarding
the co-morbidities that will be affecting the overall health of the patient. A patient admitted for a
small bowel obstruction will have nothing by mouth, if this patient is also diabetic close
monitoring of their glucose levels will need to be included in their plan of care.
Another significant part of nursing practice is medication administration. To do this
accurately and safely nurses use the five rights of medication administration. Nurses should
ensure that the right medication, at the right dose, is given to the right patient, by the right route,
at the right time, in addition to documenting the event appropriately (Lehne, 2013, p.5).
Knowledge of the medication, including the reason it is prescribed, proper administration and
possible adverse effects need to be communicated to the patient.
Skills
The nursing process starts with assessment of the patient by collecting subjective and
objective information (Lewis et al., 2007). A thorough head to toe nursing assessment is the most
valuable thing a nurse does, and can mean life or death for a patient if something is caught or
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missed. Nurses need to be keen observers of any changes in the patient’s medical status.
Auscultating their heart, lungs and bowel sounds should be one of the first things done. I tell new
nurses and nursing students to always look at the patient first, and then compare your findings to
what the previous nurses had charted.
If a discrepancy is noted ask if the change is expected or normal for the disease process,
if it shows improvement or deterioration in the patient’s condition and does the physician need to
be notified. There are nursing interventions that can be implemented in most cases prior to
notifying the physician. If a post operative patient had their Foley catheter removed greater than
six hours ago and has not voided, the nurse should first assess if the patient is producing urine.
Scan the patient’s bladder, if the patient has urine in their bladder but is unable to void have them
sit on the commode with the faucet running or run some warm water over their perineum. If the
patient is still unable to void the nurse should check to see of any standing post operative orders
were left for such an instance before calling the physician. If not, the physician should be called
and an order for a straight catheter insertion anticipated.
Skills including urinary catheter insertion are taught in nursing school, practiced during
clinical rotations, and assessed during new hire orientation. New nurses should also feel
comfortable with inserting intravenous catheters and nasogastric tubes and maintaining sterile
technique when changing dressings. Excellent communications skills are also needed for nurses.
Being able to converse with patients in a way that is both culturally competent and at an
appropriate education level is vital to ensure patient satisfaction and build a positive nurse patient
relationship.
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Attitude
I have noticed that the attitude, non-verbal and verbal signals conveyed by the nurse have
a direct reflection on the patient and family. A nurse with a positive attitude, smiling face and
caring tone of voice shows their patients that they are confident in their knowledge, sure of their
skills and enjoy their work. This puts patients and families at ease, allows them to trust a person
they just met and begins building a rapport. If a nurse enters a patient’s room with a negative
attitude, has a scowl on their face or sounds uncaring or hurried, the patient will notice. These
patients rarely build a trusting relationship with the nurse, which can in turn discourage the
patient from asking questions and offering information that may affect their care.
One way I show my patients that I am concerned with their care is charting their
assessment at the bedside. It takes less than ten minutes, and the patient gets a sense that they are
a priority and are more inclined to offer information or ask questions during that time. Nursing
school teaches us to show empathy. Our patients are under a great deal of stress. They are afraid,
sick, in pain and in an unfamiliar environment. Nurses can help them cope by showing them
respect and being cognizant of their own attitude. Something as simple as a smile to offer
comfort can make a world of difference to a patient. Explaining what they can expect during a
procedure or what lab values we are watching and why can also make the patient feel at ease.
Philosophy
Philosophy is the search for truth based on reason (Dictionary.com, 2013). In the field of
nursing we search for the best way to care for patients, advance health, improve the environment
and empower the nurse. To ensure that nurses are using scientific reliable information to
practice, research is done to provide evidence to support the actions and recommendations.
Using evidence-based practice (EBP) is crucial to ensure positive patient outcomes (Titler,
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2011). For example, Reilly et al. (2006) used EBP to create a plan to decrease the number of
catheter associated urinary tract infections by using a daily checklist to assess if the catheter
could be removed. The fewer days a catheter was in place, the lower the rate of infection (Reilly
et al. 2006). Nursing research is based on nursing theory. The core of nursing theory consists of
four metaparadigm concepts of person, health, environment and nurse (Tourville, 2003).
Tourville (2003) uses the roots of a tree to symbolize the four metaparadigm concepts of
person, health, environment and nurse in her review of nursing theory. These provide the base
for nursing philosophy, nursing research and nursing practice. The following sections will
evaluate the four nursing metaparadigm concepts in addition to nursing theory as I understand
them today and how I use them in my practice.
Person
The first metaparadigm concept is person. Person is whomever the nurse is caring for, it
can be a single person or many (Tourville, 2003). I find this basic definition to be most
applicable to my nursing career. The person is not just the patient in the bed who needs care. I
interact with patients, their family members, other nurses and nursing students. All forms of
nursing are included, education, bedside care, informatics as well as management. All nurses
need to have a person/people to work with to improve health and healthcare.
Health
The second metaparadigm concept of health used to be defined “as the absence of
disease” (Tourville, 2003). Now health is considered on a scale, ranging from optimal health and
independence to poor health and total dependence on caregivers with a focus on the quality of
life (Tourville, 2003). The patient’s perspective of their quality of life has a strong impact on
how they view their level of health. Fagerlind, Ring, Brulde, Feltelius & Lindblad (2010) found
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an overlap in patient responses when asked to define the terms health and quality of life. One
way the study evaluated quality of life was asking about the environment in which the person
lived (Fagerlind et al. 2010).
Environment
The living environment is only one place where nursing care can take place. Hospitals
being the most common, along with nursing homes, clinics and schools can all be the setting for
nursing actions (Tourville, 2003). In my nursing career so far I have had the most experience in
the hospital environment. Most patients find being admitted to the hospital very stressful, this
stress can impact their disease process. So it is crucial that the patient be made as comfortable as
possible in their hospital room. I find comfort in the familiarity of the hospital and the routines.
The transition from acute care nurse to nursing instructor in the hospital will be a challenge.
Potentially more of a challenge will be the classroom setting in the new nursing role of
instructor.
Nurse
Carper (1978) identified “four fundamental patterns of knowing” for the nursing
profession that are “essential for the teaching and learning of nursing” (p. 13). These four
patterns are empirics, esthetics, personal knowledge and ethics and a comprehension of these
allows nurses to be more attentive to the vast array of nursing information (Carper, 1978).
Nurses use empirics through evidence based practice, using up to date research data to provide
better patient outcomes. Esthetics comes into play in nursing during patient care. Nurses must
learn to observe a patient’s behavior, interpret possible meanings and provide interventions
appropriately. Knowledge of self is important when interacting with patients and clients because
in order to be of assistance to them, the nurse must first understand themselves. Prejudices,
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attitude and confidence are exuded by the nurse are gathered by patients, thus changing the
relationship dynamic and affecting the health and wellness of the patient. Ethical behavior on the
part of the nurse as caregiver can be challenging. The nurse must balance their individual ethical
and moral code with those of the patient and family.
Nursing Theory
All nursing theory stems from the metaparadigm concepts of person, health, environment
and nurse. One theory that has helped guide my nursing practice in the past and will be
applicable to my future in nursing education is the theory of self-efficacy. Recognized selfefficacy is what a person believes they can achieve (Bandura, 1997). This does not always reflect
a person’s actual abilities. Bandura (1997) identifies four systems that affect ones self-efficacy;
cognition, motivation, mood and physical health. This has had an effect on me as a nurse in three
ways. First my own self-efficacy, do I feel capable to be a nurse? I have the cognitive ability
from nursing school and continuing education, I am motivated to help people and teach nursing
students, I need to make sure my mood is positive and caring and I am more positive and
energetic when I eat well balanced meals and exercise regularly. Secondly, as a nurse I need to
evaluate my patient’s self-efficacy to determine if they are going to be able to comply with their
treatments. I may be sending them home with a wound that needs to be dressed daily. If they
don’t have the knowledge, motivation, positive mood and understand the physical health
benefits, they may not be compliant and the wound would worsen. I would use the “Teach-Back”
technique (return explanation or demonstration) to assess their self-efficacy (Dantic, 2013).
Thirdly, I will need to assess the self-efficacy of the nursing students I will be teaching.
Stump, Husman & Brem (2012) found a need for a self-efficacy model in nursing school.
The Nursing Student Self-Efficacy Scale was created and tested (Stump, Husman & Brem,
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2012). The study results showed that the scale was a satisfactory tool to measure self-efficacy
related to psychomotor and communication skills (Stump, Husman & Brem, 2012). This would
be a tool I could bring to the institution and recommend using to assist in the evaluation of
student’s preparedness to enter the nursing field. Being physically able to complete the tasks at
hand is important, even more important is the knowing and feeling that you are able to complete
them successfully.
Conclusion
I was called to nursing to comfort, support and educate patients. I feel I have done this to
the best of my abilities, but now I have the desire to affect how the next generation of nurses will
practice. I want to impart on them the knowledge needed to care for patients in the medical and
surgical settings. I want to teach them the skills they will be required to perform on a daily basis.
I want to convey how much of an impact their attitude can have on the patient. My philosophy of
nursing, including the theory of self-efficacy and the metaparadigm concepts will guide me along
this journey. With an advanced practice role in nursing education I can achieve my goals.
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References
American Nurses Association. (2010). Scope and standards of practice: Nursing. Silver Spring,
MD. Nursesbooks.org.
Bandura, A. (1997). Self-Efficacy. Harvard Mental Health Letter. 13.9 (Mar. 1997), 4.
Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science
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Dantic, D. E. (2013). A critical review of the effectiveness of “teach-back” technique on teaching
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Dictionary.com. (2013). http://dictionary.reference.com/browse/philosophy?s=t.
Fagerlind, H., Ring, L., Brulde, B., Feltelius, N., & Lindblad, A. K. (2010). Patients’
understanding of the concepts of health and quality of life. Patient Education and
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Reilly, L., Sullivan, P., Ninni, S., Fochesto, D., Williams, K., & Fetherman, B. (2006). Reducing
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