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Running head: TRANSITION 1 Nurse Transition: BSN to MSN Deborah A. Jansen van Galen, RN, BSN, CMSRN Ferris State University TRANSITION 2 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. TRANSITION 3 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 TRANSITION 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 4 TRANSITION 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. 5 TRANSITION 6 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, TRANSITION 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 7 TRANSITION 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, 8 TRANSITION 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, 9 TRANSITION 10 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. TRANSITION 11 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 1(1): 13-23. Dantic, D. E. (2013). A critical review of the effectiveness of “teach-back” technique on teaching COPD patients self-management using respiratory inhalers. Health Education Journal 0(0): 1-10. Doi: 10.1177/0017896912469575. 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 Counseling 78(1): 104-110. Lehne, R. A., (2013). Pharmacology for nursing care 8th ed. (p. 5). St. Louis, MO. Elsevier Saunders. Lewis, S. L., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L. (2007) Medical-Surgical Nursing: Assessment and Management of Clinical Problems (p 5, 9). St. Louis, MO. Mosby Elsevier. National League for Nursing. (2012). The scope of practice for academic nurse educators. New York: National League for Nursing. Reilly, L., Sullivan, P., Ninni, S., Fochesto, D., Williams, K., & Fetherman, B. (2006). Reducing Foley catheter device days in an intensive care unit: Using the evidence to change practice. AACN Advanced Critical Care 17(3): 272-283. TRANSITION Shaughnessy, M. & Resnick, B. M. (2009). Using theory to develop an exercise intervention for patients post stroke. Topics in Stroke Rehabilitation. Mar-Apr p. 140-146. Doi: 10.1310/tsr1602-140. Stump, G. S., Husman, J., & Brem, S. K. (2012). The nursing student self-efficacy scale. Nursing Research 61(3): 149-158. Titler, M. G. (2011). Nursing science and evidence-based practice. Western Journal of Nursing Research. Sage Publications. Doi:10.1177/0193945910388984. Tourville, C. (2003). The living tree of nursing theories. Nursing Forum 38(3): 21-36. 12