Accomplishments:

December 2013

• The Burn Center became American Burn Association certified for the 3rd time (every three year review).  This was a huge undertaking and quite intimidating.  The amount of paper work, quality review, chart review, and site visit requirements were staggering, but we got through it and just found out November 11th!
• I continue to be on Scope of Practice Council and we've answered some pretty interesting questions. 
• We applied for IRB approval at the end of our last class, and I'm finding out that becoming a study participant is complicated and a lot of paperwork and inservicing has to be done.  On top of that, I'm finding that the approval process will take much longer than I knew.  
• I created a continuing education credit approved burn education module teaching new and seasoned nurses alike how to perform basic burn dressings.  It's a one hour course.  I've found that I really enjoy teaching more than any other aspect of my job. 

Nursing Research Class

    The role of the professional nurse in promotion of evidenced based practice is one that has grown in need recently.  Nursing was involved in past research more in the role of executing protocols for doctors.  As nursing has grown as a profession, then there were those "academic" nurses with PhD's that were involved in research, but never the bedside nurse.  Those at the bedside are now being called to participate fully in research by their hospitals.  No longer simply just a participant, but an active developer of research questions and implementation.  These nurses now are authors of evidenced based research articles and studies published widely, and not just in nursing journals.
     Nurses that have knowledge of the ethical and professional issues involved in gathering data, enrolling subjects, and protecting their legal, ethical and moral rights is of the utmost importance if approval is to be granted to our questions.  Dr. Ellis, of Santa Fe College, stated in our poster presentation something to this effect-Nurses have so many wonderful questions and ideas and harbor much knowledge in their particular areas of expertise.  But she went on to say that if we, as nurses, don't harness this knowledge and move it forward in a meaningful way, and share it, then it is lost.   Nursing research has been the one class that I can say has helped me grow the most.
     Previous courses have honed my writing skills, ability to use multi-media such as Power Point, Excel and organizing group projects by sharing information electronically.  This course, however, has taken all of those skills and gone a step further.  APA formatting had to be perfect, posters were created, and content was edited by group comments.  But it was the content gathering that felt more advanced, more professional and the criteria for choosing content truly had to be evidenced based.  

    The article critique summary is what I feel helped me the most.  It's a tool that I'll definitely use in my career from this point forward.  I feel that in previous class papers and discussion posts, finding interesting peer reviewed articles was simple.  In this class, paring down articles that not only addressed the subject matter but also answered a research question proved to be difficult.  On top of that, needing 10 articles didn't seem that onerous until the critique summary had to be applied.  I found that a handful of my articles had to be thrown out and my search then had to continue.  

     My research question concerned my area of interest: burns.  I wanted to find out how pruritis, a major complaint of healing burn wounds, could be reduced.  Because the standard was set so high for us in this class, I am quite confident that my research question is sound enough to actually go forward with a real study.  I'm quite excited about it.  

     In the meantime, in my own work, I continue to grow as a clinical leader with just one year of experience as of November 11th.  The last course helped me to grow from the management/people skills aspects of the job, and this course has helped me to feel more legitimate in the nursing research requirements of the job.  Not only have I learned the research "lingo" but actually know how to get started with almost any question and follow it through into a meaningful and executable study.  

Accomplishments 

Since entering the BSN completion program,  I've had a whirlwind of a year.  

• November 2013-I became the Clinical Leader for the Burn Center at Shands hospital. 
• Being a clinical leader means that I am now obligated to attain my Master's in nursing.  I have until December 2016 to complete this. I will also have to acquire a nursing certification.  I'm going back and forth between CCRN and a wound care certification.  
• I've joined the hospital's Scope of Practice Council. 
• The Burn Center has engaged in an evidenced based research project to find out the Modified Early Warning System Sepsis Recognition score that is useful in determining impending sepsis in the burn population. I created and presented the poster for this project at the hospital's Quality Conference. We are past the early stages and are applying for IRB approval this week.

Nursing Leadership and Management

     My experience working within a team to complete a Quality Improvement project was certainly a learning experience.  Although the team was very excited about our project-improving post discharge cleaning processes to reduce hospital acquired infections, different personalities was our challenge. It was funny that we’d all just taken a conflict resolution style inventory, and sure enough, the group project proved to reveal those styles. I was proud that although we didn’t always agree, the group was civil and compromising and able to easily come to consensus that worked for the project outcomes and goals. 

Ultimately, the project presentations proved that not only our team, but all of the teams were incredibly competent.  The projects were quite professional and the presentations were interesting and it was apparent that the nurses in this program have grown in confidence, curiosity, and empowerment by developing their professional practice. I left the presentation day potluck very proud of the group as well as feeling as if I’m already reaping the benefits of obtaining my BSN. 

     The weekly reading by Staffileno & Carlson (2010) emphasizes that nurse managers need to encourage this same sort of curiosity and ability to engage in and understand evidenced based practice.  However, Staffileno & Carlson (2010) comment that management teams need to allow for this engagement in formalized ways that include not just time, but mentoring and education.  I will certainly use some of the suggestions for teaching and encouraging evidenced based practice understanding: Journal Clubs as well as having someone come from Nursing Education to help us all learn how to better search databases and do literature review.  Actually, I feel that database research would be a nice addition to this program, perhaps integrated into the first Transition to Professional Nursing course. 

     The BSN completion program has helped emphasize the need for multi-disciplinary teams from everything to giving report and rounding to delivering patient centered care.  I head a monthly for the Burn Center at Shands where the emphasis is on patient outcomes: pressure ulcers, readmissions, sentinel events, and the like. These patient outcomes are easily measured because the hospital keeps track of them for us and my job is to discuss amongst an interdisciplinary team the possible causes for them.  The other part of my job is to come up with improvement initiatives.   The experience of working with a team to complete the Quality Improvement (QI) class project helped me in my own practice by emphasizing that outcomes need to be measurable. I’ve grown from implementing changes that “will obviously” have better outcomes, to a more mature way of implementing changes that I can ensure that are measurable and perhaps even publishable.  I have two projects going on at this time: A modified early sepsis warning measurement system (MEWS) for burn patients as well as a high touch surface area cleaning process in the Burn Center. Each will be measured to see if our numbers improve: What number is most predictive of impending septicemia for burn patients and will implementing the early warning decrease septic events?  And for the second project: Will implement a twice a day high touch surface area cleaning system and check-off sheet reduce hospital acquired infections and decrease the amount of bioburden that is cultured from those high touch surface areas? 

     Finally, the course content that I find the most challenging was reading about the various ways in which staffing was figured.  It was quite enlightening reading about hours per patient day.  What the reading revealed, along with investigating the way in which my area of practice has tried over the years to adequately staff, is that this challenge is one that is ongoing and incredibly complex. 

References

Stafffileno, B.A., & Carlson, E. (2010).  Providing direct care nurses research and evidence-based   

     practice information: An essential component of nursing leadership Journal of  Nursing Management,         18,  p. 84-89.  

Advanced Health Care Assessment

     The Advanced health care assessment class has by far been the most challenging in terms of time spent on the class and dusting off the old study skills of reading and a lot of memorization.  The class has also been my favorite and I wouldn't have minded spending maybe 2 "mini mesters" on assessment skills.  

     When beginning the program, the amount of writing was painstaking.  Now, it's not a problem at all.  This class has been the most traditional: actual face to face contact hours, a textbook, and in person check-offs, group projects and a final exam (rather than a final paper).  

     The textbook is comprehensive, beautifully filled with photographs and illustrations.  I rented the book, but will end up buying it.  The book by Jarvis (2012) considers pyschosocial, cultural and developmental factors that affect the health assessment process.  For instance, while simultaneously learning how to systematically approach a complete nutrition assessment, the author not only describes needs of the aging body, but explains factors such as limited income after retirement and social isolation that affect nutrition. 

     In addition to the book being laid out clearly, the margins are highlighted with implications of the techniques being described and possible abnormal findings. There is an emphasis on appropriate communication and interviewing techniques to facilitate the health assessment such as asking open ended questions and not talking down to the patient. When suspicious of possible drug abuse, for instance, the practitioner should not be perceived as judgmental, but rather, interested in fact finding and able to offer practical solutions and treatment. 

     Finally, in order to gather full data and conduct and appropriate and useful assessment, the techniques we learned were all centered around systemization.  Subjective to objective; head to toe; inspection then palpation, percussion and auscultation.  Where appropriate, the systematic approach is, of course,  tailored to the system itself.  For example, the abdomen should be auscultated before being palpated. 

     I've felt that I've grown in competency and skills after having completed this course and look forward to the next semester's research course...with a healthy bit of nervousness. 

Ethics in Nursing

Ethics in Nursing

            “The focus on caring, particularly for vulnerable people, establishes the ethical dimension of nursing practice; the NMC and the general public expect high standards in nursing practice” (Convey,  2012, p. 51).  The expectation that nurses practice ethically is wholly embedded into the nursing profession, the care that nurses give at the bedside, and is evidenced by the high level of respect that the public gives to the nursing profession. 

            The principles of ethics include beneficence, non-maleficence, justice, fairness, fidelity, and veracity.  These principles were defined by the Greeks and, briefly, the “goal of ethics is to delineate moral duties and obligations within a manageable set of rules or principles” and are based on “rightness …viewed in terms of good produced as consequences of action” (Racher, 2007).  The principles of ethics seek to give autonomy to persons so that they have control of their own life and outcomes while ensuring that those decisions are informed and that the person making their own decisions is competent to make those decisions.  Ethics committees are asked to be involved when these principles are either being denied to a person, or when two or several parties have conflicting interests. Ethical dilemmas arise when, “there are at least two courses of action, but with each option being problematic” (Fletcher et al. 1995).

            To give excellent care, to seek and protect the autonomy of patients, all while using the principles of ethics is rewarding when patients are easily able to first advocate for themselves.  In cases where a patient is unable to express their wishes, family members have differing views, or when medical staff does not act in the best interest of the patient, ethical dilemmas arise. 

            This class explored the role of ethics committees in solving ethical dilemmas.  Unfortunately, after using ethical committees, we’ve seen in cases studied in this class, there may not be one glaringly obvious “good” choice.  Ethical dilemmas, in fact, may end up not being solved, but perhaps being decided on in terms of the greatest good for most of the parties involved while keeping the focus on the patient.

            The class continued to explore the difficulty in advocating for patients when ethical dilemmas arise.  We explored barriers to advocacy and how nurses may face institutional resistance when met with ethical dilemmas and advocating for vulnerable patients. Iyer (2012) recounts the story of Amanda Trujillo who was on welfare and a single mother with a dream of becoming an RN, which she eventually did, achieving a master’s degree in nursing.  After calling a hospice consult for her patient, the patient decided against liver transplantation and Amanda was the subject of the doctor’s fury, sent to the board of nursing by her institution, and fired (Iyer, 2012).  Because Amanda discovered that her patient knew little about her scheduled liver transplant, she thought the consult would be helpful.  Despite not needing a doctor’s order for the consult, her institution said she was operating outside of her scope of practice (Iyer, 2012).  Ms. Trujillo is now back on welfare (Iyer, 2012). 

            Not only did the class explore difficult ethical dilemmas through actual cases, but issues of unequal access, language barriers, and a multitude of social barriers such as poverty that constitute breaches of ethics.  Nurses, doctors, nurses’ associations and institutions must all work together as advocates for those that are vulnerable to conquer lack of access and resources. 

References

Convey, H. (2012).  Ethical practice in nursing care.  Nursing Standard,  27(13), 51-56.

            Fletcher, N., Holt, J., Brazier, M., and Harris, J. (1995).  Ethics, law and nursing.      

            Manchester University Press, Manchester.

Iyer, P. (2012). Amanda Trujillo RN – fired for being a patient advocate. Nursing Malpractice(4^th ed.). 

           Retrieved from:  http;//medleague.com/blog/2012/030120amanda-trujillo-  rn-fired-for-being-a-  

          patient-advocate/

Racher, F. (2007). The evolution of ethics for community practice.  Journal of Community Health  

         Nursing, 24(1), 65-76.