Competencies In Medical-Surgical Nursing PDF

COMPETENCIES IN MEDICAL-SURGICAL NURSING Entry-level nursing programs, including associate, baccalaureate, master's (including Clinical Nurse Leader), and doctoral degrees, focus on the preparation of nurses to practice competently in various medical-surgical settings. Competency in the management...

COMPETENCIES IN MEDICAL-SURGICAL NURSING Entry-level nursing programs, including associate, baccalaureate, master's (including Clinical Nurse Leader), and doctoral degrees, focus on the preparation of nurses to practice competently in various medical-surgical settings. Competency in the management and coordination of adult medical-surgical patients requires a strong background in the sciences, including anatomy and physiology, chemistry, microbiology, pathophysiology, and pharmacology. Throughout this text, there is an emphasis on correlating the rationales for nursing care of this adult patient population to the physiological and pathophysiological bases of selected disease processes. Promoting an understanding of the relationships between the physiology, pathophysiology, clinical manifestations, and management of these disorders fosters more accurate interpretation of data, enhanced critical thinking, sound clinical judgment, and better clinical decision making. Box 1.1 Academy of Medical-Surgical Nurses Strategic Framework Vision AMSN is the recognized leader in medical-surgical nursing. Mission AMSN is a dynamic community of medical-surgical nurses that are committed to quality patient care through professional development, certification, scholarship, and advocacy. Values Dedication Passionate devotion to the well-being of medical-surgical nurses and those under their care Transformation Lead innovation in all aspects of medical-surgical nursing Collaboration Actively seek to engage with members of the interdisciplinary team, other nursing specialties, and external stakeholders to achieve common goals that reflect and promote strategic goals and values Advocacy Courageous and proactive in advocating for medical-surgical nurses and patients, from the point of care to the boardroom, and from the payer to the legislative arena Strategic Plan The AMSN strategic plan is a living document that guides the work of AMSN. The purpose of the plan is to focus all AMSN initiatives on achieving AMSN's mission of commitment to quality patient care through professional development, certification, scholarship, and advocacy. Adapted from American Academy of Medical-Surgical Nurses. (2023). Mission, Values, and Strategic Direction. https://www.amsn.org/about-amsn/leadership-and-governance/mission-values-and-strategic-direction This focus on competency is particularly important because the Nursing Executive Center of the Advisory Board reported that many nursing school graduates demonstrate an academic-practice gap. The Nursing Executive Center serves nursing administrators through data collection around best practices, strategic initiatives, and operational issues, including transition to practice issues. Acute care agencies consistently report that it continues to take longer for new registered nurses to achieve clinical competency despite increased resources used for onboarding and training. In this specific study, nursing executives described that new graduates lacked the expected knowledge and competency in the following areas: Box 1.2 Domains of Nursing Practice for Medical-Surgical Nursing Certification Patient/Care Management Holistic Patient Care Elements of Interprofessional Care Professional Concepts Nursing Teamwork and Collaboration Source: Medical-Surgical Nursing Certification Board. (2023). Domains of Medical-Surgical Nursing Practice. https://www.amsn.org/sites/default/files/documents/CMSRN-Blueprint-2023.pdf Knowledge of pathophysiology of patient conditions (34%)\* Knowledge of pharmacological implications of medications (28%)\* Decision making based on the nursing process (20%)\* Interpretation of assessment data (18%)\* Although this study was completed in 2008, the issues related to readiness for practice of new graduate nurses continue, particularly in acute care settings. Two specific concerns that are identified by administrators of new graduate nurses are failure to notice (changes in their patient's condition) and failure to act, which may contribute to negative patient outcomes. There is a growing body of knowledge related to addressing this academic-practice gap through the establishment of academic-practice partnerships. Suggested strategies to better prepare the nurse graduate for the realities of practice include the increased use of simulation in nursing education programs, extended transition to practice and residency programs, emotional support related to the stress encountered during the onboarding period, and the establishment of academic service partnerships. The two most common reasons that new graduate nurses are disciplined are (1) failure to notice changes in patient status and (2) failure to act when a patient is deteriorating. Clinical Judgment The National Council of State Boards of Nursing (NCSBN) in the 2021 RN Practice Analysis Research Brief defines clinical judgment as "the observed outcome of critical thinking and decision making. It is an iterative process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care." Clinical judgment is a required competency needed in the increasingly complex environment in which registered nurses practice. The American Association of Colleges of Nursing (AACN) describes the importance of clinical judgment in The Essentials: Core Competencies for Professional Nursing Education. In this document, clinical judgment is described as a key attribute of professional nursing, and the process nurses use to make decisions based on nursing knowledge, other disciplinary knowledge, critical thinking, and clinical reasoning. Required to understand and interpret information, the decisions made based on clinical judgment directly influence outcomes of care. Because of the continued academic practice gap, along with the high acuity clinical areas in which new graduate nurses practice, NCSBN developed the Clinical Judgment Measurement Model (CJMM) as an approach to measure new graduate nurses' clinical judgment. This model measures clinical judgment based on the registered nurse's ability to: Recognize cues Analyze cues Prioritize hypotheses Generate solutions Take actions Evaluate outcomes Beginning in the Spring of 2023, NCSBN started integrating Next Generation NCLEX-RN (National Council Licensure Examination for Registered Nurses) questions into the licensure examination in an effort to measure clinical judgment of nursing graduates. Integrated in this textbook are activities based on the CJMM that use the chapter Case Study called "Making Connections to Clinical Judgment" to support students in using the clinical judgment steps to analyze the Case Studies. Competencies Related to the Nursing Process Equally important to the practice of medical-surgical nursing are competencies in the nursing process, clinical decision making, evidence-based care, patient-centered care, quality and safety, and interprofessional practice. The nursing process includes assessment, diagnosis, planning, implementation, and evaluation and ultimately guides patient care. Throughout this text, there is a strong emphasis on using the nursing process to guide the delivery of safe, effective, and patient-centered nursing care. The nursing process and clinical judgment guide the nurse's clinical decision making, and play significant roles in the medical-surgical nurse's decision-making process with patients and families in the current healthcare environment. The relationships between the nursing process, clinical judgment, and clinical decision making are presented in Figure 1.1. In this figure, the iterative processes of both the nursing process and clinical judgment are integral to safe, effective clinical decision making. Higher patient acuity and increased complexity of patients' care needs, accompanied by shorter lengths of stay in acute care settings, place the nurse in the vital role of ensuring that patients are prepared for transitions to different levels of care. Facilitating the patient's and family's understanding of treatment plans and discharge teaching is a primary responsibility of the medical-surgical nurse. Connection Check 1.1 Which factors have led to the expansion of medical-surgical nursing from traditional acute care facilities to other settings? (Select all that apply.) A.  Increases in healthcare complexity B.  Shortage of registered nurses C.  Changes in insurance coverage D.  Shortened hospital lengths of stay E.  Low salaries for registered nurses in hospitals EVIDENCE-BASED NURSING CARE Evidence-based nursing practice is the foundation of professional nursing practice. Based on a problem-solving approach to healthcare delivery, nursing care practices and protocols are based on the best evidence from research studies and the expertise of clinicians. Medical-surgical nursing incorporates evidence-based practice principles in order to provide the highest-quality and most cost-effective care to patients and families. Evidence-based care is characterized by clinical decisions that are based on the use of the best available evidence, clinical expertise, and patient preferences (see Evidence-Based Practice). The steps of the evidence-based process are listed in Box 1.3. FIGURE 1.1 The Nursing Process and Clinical Judgment Model The utilization of the best evidence requires the registered nurse to possess competencies in locating and evaluating the quality of data. Typically, there is a clinical question or problem identified that guides the initiation of an evidence-based project. Once the question has been defined, a literature review is conducted to assess the current state of the science around the question. Skills in conducting effective literature searches and analyzing findings are crucial for the nurse in locating and evaluating the quality of evidence required to guide clinical practice. Increasingly, nursing programs incorporate these search strategies into their curriculum, often in collaboration with college/university libraries. Once data have been located, the evaluation of the quality of the evidence is the next step in the process. Box 1.4 outlines one process for the evaluation of data and describes the types of data that are used to determine the quality, validity, and reliability of evidence. The lowest numerical rating of the level of evidence in this approach correlates with the highest level of evidence. For example, systematic reviews of randomized controlled studies (Level I) are the highest level of evidence because they include data from selected studies that randomly assigned participants to control and experimental groups. Randomized controlled studies are considered the gold standard of research, with their findings most valuable. Level II evidence is based on the results of a single randomized controlled study. Quasi-experimental studies (Level III) also use the control and experimental groups but lack the random assignment. Research that is designed as a case-control study includes two groups, those with a specific disorder and those without, and then comparisons are made between the two groups. Cohort studies use a group of people (cohort) who are initially free of disease and are then followed over a period of time to examine whether the development of new cases differs between those with and without exposure to some type of disease, environmental hazard, or other factor. Both case-control and cohort studies are often conducted in epidemiological research and are considered Level IV evidence. Descriptive and qualitative studies do not use an experimental design with control and experimental groups; they provide findings based on observations of populations and phenomena. Systematic reviews of descriptive studies (Level V), because they include numerous studies as opposed to a single descriptive study (Level VI), provide a higher level of evidence. The lowest level of evidence (Level VII) is expert opinions from individuals and committees. Although higher levels of evidence are preferred, there are not always randomized controlled studies available to answer all questions posed in an evidence-based review of the literature. Evidence-Based Practice Medication Administration Errors One of the major responsibilities of registered nurses in the inpatient setting is medication administration, and medication errors are a critical patient safety issue. Because quantitative studies may overlook the overt causes of medication administration errors, this qualitative study was conducted to look at nurses' perceptions of the causes of medication errors. The method was a literature search that included publications from February 2019 until 2020. Inclusion criteria were as follows: Studies that used qualitative or mixed methods design Reports that included qualitative data on nurses' perceived causes of medication administration errors Studies published in English Sixteen articles met the inclusion criteria and were assessed using the Critical Appraisal Skills Programme (CASP) tool. Thematic analysis was performed with perceived causes of errors labeled as knowledge based, personal, or contextual. The results were as follows: The lack of medication knowledge was the primary knowledge-based factor. Fatigue and complacency were the personal factors. Heavy workloads and interruptions during medication administration were the major contextual factors. The causes of medication administration errors were perceived by nurses to be multifactorial and often stemmed from systems issues. Schroers, G., Ross, J. G., & Moriarity, H. (2021). Nurses' perceived causes of medication administration errors: A qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety, 47, 38--53. Box 1.3 Steps of Evidence-Based Practice Develop the question. Search and collate the best evidence. Evaluate the quality of the evidence. Integrate evidence into practice. Evaluate outcomes of practice change. Disseminate the evidence. Box 1.4 Evaluating Levels of Evidence Level I Evidence from systematic reviews of randomized controlled studies (RCTs) Level II Evidence from at least one RCT Level III Evidence from quasi-experimental studies Level IV Evidence from case-control and cohort studies Level V Evidence from systematic reviews of descriptive or qualitative studies Level VI Evidence from a single descriptive or qualitative study Level VII Evidence from expert individual authorities or committees The importance of evidence-based care is also reflected in the American Nurses Credentialing Center (ANCC) Magnet® Recognition program, in which Magnet status is awarded to healthcare facilities that demonstrate excellence in the recruitment, recognition, and retention of nursing staff, as well as excellence in patient care and quality. Because quality patient care is associated with a foundation in evidence-based findings, the AMSN's Scope of Medical-Surgical Nursing Practice provides dissemination of evidence-based practice guidelines for medical-surgical nurses. Medication administration errors are a critical patient safety issue in inpatient settings. When administering medications, it is imperative that the nurse minimize interruptions to decrease medication errors. Connection Check 1.2 In designing an evidence-based practice guideline for a medical-surgical unit, which source provides the most reliable information? A.  Content from a textbook B.  Manuscript in a nursing journal C.  Results from research studies D.  Information from a professional activity PATIENT-CENTERED CARE IN THE MEDICAL-SURGICAL SETTING The importance of patient-centered care is highlighted in the 2003 report Health Professions Education: A Bridge to Quality by the Institute of Medicine (IOM). As acute care hospital lengths of stay shorten, the patient's interactions with members of the healthcare team and particularly one-on-one time with the primary healthcare provider are affected. Complicating these patient encounters are greater requirements for documentation and justification for care. From the patient's perspective, the requirements of the system often seem to overshadow the patient's concerns. The results of patient satisfaction surveys that evaluate hospital stays often report dissatisfaction regarding time spent with members of the healthcare team. Patient-centered care is a benchmark that acute care facilities are evaluated against, and nursing care is an important component of this evaluation. Because nursing care is provided 24 hours a day in acute care settings, patients often base their evaluations of the quality of their care on interactions with nursing staff. Patient-centered care focuses on treating patients and families with dignity and respect and engaging patients and families in decision making about care decisions. Competencies of medical-surgical nurses that are closely associated with patient-centered care include effective communication skills, empathy, caring, and compassion. Equally important are the clinical competency and knowledge base of the registered nurse. The relevance of patient-centered care is further underscored by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a survey that provides a standardized approach to collecting data from patients about their experiences in hospitals. The nine essential topics included on the HCAHPS survey are listed in Box 1.5. Patient-centered care and communication are also incorporated into The Joint Commission (TJC) Standards for Hospitals. The Joint Commission (TJC) is an independent, not-for-profit organization that accredits and certifies approximately 80% of hospitals in the United States. Accreditation and certification by TJC are recognized as the standard of patient care, effectiveness, and safety and foster continuous process improvements. Aspects of patient-centered care are incorporated into the accreditation, including data related to patient participation in the plan of care and visitation rights. The mission statement of TJC focuses on continuously improving healthcare for the public through the evaluation of healthcare organizations, and inspiring them to excel in providing safe and effective care of high quality and value. The Beryl Institute is also an organization that fosters patient-centered care through the "patient experience" that is influenced by all the interactions and experiences encountered, based on the organization's culture and practices. Results from a 2017 study by The Beryl Institute found that efforts focused on supporting patient experiences are expanding, are a top priority for healthcare agencies, and can be tied to positive healthcare outcomes. Consistent with TJC's mission, The Beryl Institute supports patients and families being well informed and actively involved in all healthcare decisions. Box 1.5 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Topics Communication with nurses Communication with doctors Responsiveness of hospital staff Communication about medications Discharge information Care transition Cleanliness of the hospital environment Quietness of the hospital environment Overall rating of hospital Recommendation of hospital Source: Centers for Medicare & Medicaid Services. (2022). HCAHPS. About the Survey. https://www.hcahpsonline.org/\#AboutTheSurvey Connection Check 1.3 The medical-surgical nurse needs to be knowledgeable of which organization that scores patient-centered care via a telephone survey of selected patients after discharge? A.  The Joint Commission B.  The Beryl Institute C.  The Carnegie Institute D.  The Hospital Consumer Assessment of Healthcare Providers and Systems PATIENT SAFETY OUTCOMES Providing safe, quality care is a priority for medical-surgical nurses. The Joint Commission annually publishes National Patient Safety Goals aimed at improving patient safety through goals that focus on potential problems in the healthcare setting. The 2022 goals identified the following areas to improve patient safety: Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery These patient safety goals are integral to safe, quality patient care in the medical-surgical setting. Accurate patient identification is required throughout the patient experience, especially during assessments, while preparing patients for procedures and surgical procedures, and during medication administration. Effective staff communication is also integral to safe patient care, particularly during "hand-offs," such as change-of-shift reports, receiving patients, and transferring patients to other departments. The SBAR (Box 1.6) is one approach to decreasing communication barriers and focuses on a standard way to state the Situation, Background, Assessment, and Recommendation of patient events. SBAR enhances communication with healthcare providers, and nurses often use SBAR to report changes in patient conditions. Box 1.7 provides an example of SBAR communication between the healthcare provider and nurse around a patient demonstrating difficulty voiding after a surgical procedure. Safety measures around medication administration have been implemented in medical-surgical settings and include practices that prevent interruptions during the preparation and administration of medications. Additionally, the nurse must follow the rights and responsibilities required for safe medication administration and ensure that the rationales for all medications are associated with the patient condition. Preventing mistakes in surgery is another area relevant to medical-surgical nurses as patients are prepared for surgical procedures. Box 1.6 The SBAR Approach for Effective Communication SBAR is an acronym that correlates to: Situation: Brief statement of the problem or issue being addressed Background: Data related to the current situation Assessment: Summary of causes, significance, and severity of situation Recommendation: Specific actions needed to address the situation The SBAR method provides a consistent process for communication, particularly in high-risk situations. Of particular value is the focus on making a recommendation that focuses on a definitive approach to addressing the issue or clinical problem. Box 1.7 SBAR Example Situation: Hello, Dr. Jones. This is Steve, the registered nurse caring for Ms. Sandra Williams in Room 732 on South Wing. I am contacting you because she arrived from the postanesthesia care unit (PACU) and has not voided in more than 6 hours. Background: She was admitted to the hospital this morning, and you performed a lumbar laminectomy this morning for a herniated disc at L4--L5. Assessment: Ms. Williams is complaining of inability to void. According to her operative reports, she received 1,500 mL of IV fluid during the surgical procedure and in the PACU, and the indwelling catheter was removed prior to transfer from the PACU 6 hours ago; at the time, she had 800 mL of urine output. She has received an additional 250 mL of IV fluid since arriving on the unit. Recommendation: I recommend that an intermittent catheterization be performed at this time. In preparing a patient for a surgical procedure, it is important to mark the correct place on the patient's body where the surgery is to be performed. Medical-surgical nurses play an integral role in the prevention of infection and surgical errors. Hospital stays may be extended because of infection, particularly those associated with hospital-acquired infections. Many acute care facilities have implemented increased surveillance and evidence-based guidelines to prevent these types of infections, including catheter-associated urinary tract infections and central line infections. Additionally, surgical settings have implemented "time-outs" (requiring all personnel involved in the procedure to stop to make sure that the patient is identified, the correct anatomical site is identified, and all equipment is in working order) and special procedures for marking surgical sites. Better patient outcomes are associated with effective communication and collaboration in patient care settings. The proper use of alarm settings on equipment used for patient monitoring is also essential in the medical-surgical setting. The nurse must ensure that the alarm parameters are individualized to the patient, as well as ensuring that the alarms are heard and responded to in a timely manner. Because of the increased emphasis on quality and safety, in 2005 the Robert Wood Johnson Foundation funded a project focused on educating nursing students on patient safety and healthcare quality. These funds established the Quality and Safety Education for Nurses (QSEN) initiative designed to prepare nurses with the required knowledge, skills, and attitudes to foster continuous improvement of quality and safety in healthcare settings. Based on the IOM's recommendations (Box 1.8), the QSEN initiative developed competencies for both prelicensure and graduate nursing students (Box 1.9). Connection Check 1.4 The medical-surgical nurse implements SBAR to promote effectiveness in which aspect of quality and safety in patient care? A.  Surveillance B.  Communication C.  Organization D.  Cost-effectiveness Box 1.8 Institute of Medicine's Competencies for Health Professionals Provide patient-centered care Work in interdisciplinary teams Employ evidence-based practice Apply quality improvement Utilize informatics Box 1.9 Quality and Safety Education for Nursing (QSEN) Competencies Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice (EBP) Quality Improvement (QI) Safety Informatics INTERPROFESSIONAL COLLABORATION AND COMMUNICATION Because of the complexity and high acuity of most adult patients in medical-surgical settings, interprofessional collaboration is imperative to the promotion of effective patient outcomes. In 1999, the IOM reported in To Err Is Human: Building a Safer Health System that between 44,000 and 98,000 deaths occurred in U.S. hospitals because of preventable medical errors. In 2009, another report by the Institute of Healthcare Improvement estimated that there were approximately 40,000 incidences per day in U.S. hospitals that resulted in patient harm. In both of these studies, ineffective communication among the interprofessional healthcare team was identified in a root-cause analysis of these medical errors. The Joint Commission includes an accreditation standard that addresses the importance of effective communication. Medical-surgical nurses are members of interprofessional healthcare teams and in acute care settings are often in the role of care coordinator. The nurse participates in interprofessional rounds with the physicians, advanced practice registered nurses, pharmacists, discharge planners, social workers, and other members of the healthcare team. Additionally, because nurses are the primary direct provider in the acute care setting, they are often the key to communication between the various healthcare members, as well as with specialists and consultants who may be episodically involved in the patient's care. Effective clinical reasoning and communication skills are crucial to this role of the medical-surgical nurse as a care coordinator. (The roles of care coordinator and interprofessional teams are discussed in Chapter 2.) With the increased focus on interprofessional patient care teams, attention is also being given to the importance of educating future healthcare providers together. Faculty at schools of medicine, nursing, pharmacy, social work, and other healthcare professional educational settings are working collaboratively to design and implement interprofessional educational programs. The use of patient care simulations using high-fidelity mannequins provides safe environments for these future healthcare team members to practice interprofessional communication and teamwork. This increased focus on educating future healthcare providers together is based on findings of increased safety and quality in hospitals with effective interprofessional care teams. Connection Check 1.5 Which outcome of interprofessional teams is associated with an increased focus on educating health professional students together? A.  Decreased hospital costs B.  Increased safety and quality C.  Decreased length of stay D.  Increased patient satisfaction CHAPTER SUMMARY Medical-surgical nursing is a specialty area characterized by competencies that are applicable for patients across the healthcare continuum, from acute care hospitals to home settings. As members of the largest subspecialty in nursing, medical-surgical nurses are eligible for certification in this practice area through the AMSN or the ANCC. Key to providing safe, effective, person-centered care is the use of the nursing process and clinical judgment. Foundational to medical-surgical nursing are evidenced-based practices that foster the delivery of safe, effective care that is based on research findings and clinical expertise and incorporates patient participation. Another growing focus of medical-surgical nursing is patient-centered care, which is also an important benchmark for acute care facilities. Patient-centered care focuses on treating patients and families with dignity and respect and engaging patients and families in decision making about care decisions. The importance of patient-centered care is demonstrated by its incorporation into TJC's Accreditation Standards for Hospitals. Interprofessional coordination and teamwork are also essential to effective patient outcomes in the complex health system in the United States. Medical-surgical nurses work closely in interprofessional teams including providers, social workers, pharmacists, and other disciplines to plan and implement the best evidence-based care.