Running head: SELF ASSESSMENT OF NURSING PRACTICE STANDARDS

Self Assessment of Nursing Practice Standards Tamara Putney Ferris State University

SELF ASSESSMENT OF NURSING PRACTICE STANDARDS Abstract Adhering to established national guidelines and standards is of utmost importance when

practicing as a professional nurse. This paper compares and examines my current intensive care nursing practice to standards set forth by the American Association of Critical Care Nurses (AACN). Competency in the standards of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation are reviewed and compared to current practice. A personal development plan to maintain or improve competency provides established measurable goals, an action plan to attain the goals, and timelines to evaluate the progress toward all goals. Although proven competent in all standards as set forth by the AACN, it is identified that self evaluation of personal and professional growth must be ongoing to promote optimal patient outcomes. Keywords: self-assessment, nursing, practice standards, competency in practice

SELF ASSESSMENT OF NURSING PRACTICE STANDARDS Self Assessment of Nursing Practice Standards To be certain that my practice as a nurse is at the highest professional level possible, and is reflective of the standards as set forth by the American Association of Critical Care Nurses (AACN), a comparison and evaluation must be made using my current practices and beliefs. This comparison will serve as a self-assessment of competency to the standards. In addition, an

outlined professional development plan to maintain current practice standards and achieve future goals will be reviewed. It is imperative to continuously scrutinize my practice and the environment around me, in order to become a more effective caregiver and leader in the profession of nursing. Professional Background I have two roles in my profession as a registered nurse. I am a bedside intensive care unit (ICU) nurse, and a part time nurse informaticist for the clinical informatics department. Providing quality care at the bedside and ensuring optimal patient outcomes is difficult if forces around the practice are not congruent, intuitive, safe, efficient and effective. Working as an informaticist, I have the opportunity to make the computerized order and documentation system safer and more efficient, which has proven to promote quality in nursing practice and help promote optimal patient outcomes. I have been an ICU bedside caregiver for 10 years. It is this critical care role that will be compared to all standards of critical care practice. AACN Standards of Practice vs. Current Professional Behaviors Standard 1: Assessment In reviewing the standard of assessment as set forth by the AACN (2008) my practice is very competent. The standard states, The nurse caring for the acutely and critically ill patient collects relevant data pertinent to the patients health or situation (American Association of

SELF ASSESSMENT OF NURSING PRACTICE STANDARDS Critical Care Nurses [AACN], 2008, p. 10). My competency in this standard is evident by the fact that I understand the importance and value of a comprehensive patient assessment, and can

use and prioritize the information in a way to drive the diagnosis and care plan of the patient in a direction that promotes quality outcomes. Understanding the importance of patient history, family involvement, utilizing evidence and resources, maintaining an ethical attitude, performing responsible documentation, and listening to the patient or family are all key parts of this standard of assessment. Critical patients routinely require hourly head to toe assessments. A complete understanding of how to think proactively and prioritize the needs of the patient is critical. A clinical example that demonstrates competency of this standard of assessment is with the care of a patient with a traumatic brain injury. Neurological assessment skills in relation to entire body systems are crucial to understand, as this is a patient condition that could quickly deteriorate and result in death if alterations from norms are not detected. Assessment skills, understanding how to communicate with others, and utilization of appropriate protocols is imperative and can save patient lives. Standard 2: Diagnosis The standard of diagnosis states, The nurse caring for the acutely and critically ill patient analyzes the assessment data in determining diagnosis and care issues AACN, 2008, p. 11). When caring for critically ill patients I am able to utilize the assessment and trended data to direct the care of the patient. It is critical to understand the difference between nursing and medical diagnoses and utilize the appropriate intervention in response to the situation. Understanding prioritization of needs and relationships between hemodynamics, metabolic function and response of body systems are just a few factors critical to meeting this standard of diagnosis. A specific example from my critical care practice with patients suffering from

SELF ASSESSMENT OF NURSING PRACTICE STANDARDS traumatic brain injury is when assessment data from lab work and hemodynamic function is examined. Understanding correlations between central venous pressure (CVP), mean arterial pressure (MAP), and hemoglobin levels could elicit nursing or medical interventions based on interpretation of assessment, diagnosis and trends. In the case of low CVP and MAP with normal hemoglobin the best protocol driven option may be to administer fluids. The type of fluid would be driven by the value of other labs, which would require more critical thinking and

assessment to properly diagnose when a change is needed. Validation of the correct intervention based on diagnosis from the patient assessment would be seen in the patient response to the intervention. Also, a very important part of critical care nursing diagnosis is the utilization of multidisciplinary rounds. Understanding the importance of a team approach to diagnosing based on assessment is important to promoting optimal outcomes. I believe my practice is currently competent in this standard. Standard 3: Outcome Identification The standard of outcome identification states, The nurse caring for the acutely and critically ill patient identifies outcomes for the patient or the patients situation (AACN, 2008, p. 11). With this standard it is important to understand that the patients outcomes in critical care will change from hour to hour or even minute to minute. Outcomes of care based on assessment, diagnosis and patient response and are made in conjunction with all family and/or patients whenever possible (AACN, 2008). When caring for the critically ill it is important to understand that outcomes and plans of care need to be dynamic and change as conditions change. Continuity of care, utilization of available resources, and critical thinking to develop appropriate outcomes, is imperative. In clinical practice, outcomes identification in caring for a critically ill patient involves making goals and outcome realistic, measurable and achievable based on

SELF ASSESSMENT OF NURSING PRACTICE STANDARDS assessment and diagnosis. Measuring and documenting patient progress is essential, especially

with critical patients because even small changes in condition can elicit a change in the direction of care. For example, an intubated patient would have an outcome to be weaned from the ventilator, but that outcome would need to take into account the stress weaning may have on other body systems. If the patients cardiovascular system responded with extreme tachycardia, the process of weaning may need to be less aggressive until the cardiovascular system was stable. Identification of outcome options is very important. I believe I meet this standard of outcome identification but experience in practice, establishing a culture of learning, and keeping up with best evidence practice will improve outcomes and better my practice. Standard 4: Planning The AACN (2008) standard of planning states, The nurse caring for the acutely and critically ill patient develops a plan that prescribes interventions to attain outcomes (p. 12). Once assessment data is diagnosed and outcomes are identified the individualized plan of care is developed. This plan is essential to promote continuity of care, progress the patient toward optimal health, or in some cases allow for dignity of a peaceful death. In clinical practice, with critically ill patients, I prove competent because I can correlate the needs of the patient, understand the assessment, diagnosis and expected outcomes to formulate realistic plans of care. A specific example in critical care is developing a plan for a traumatic brain injury patient. The plan must include measurable outcomes based on the condition of the patient and the medical and nursing diagnoses developed. The plan must be made in conjunction with the multidisciplinary care team. The plan should be thoroughly documented with target dates and the patient must be able to progress on the plan to optimal health, if at all possible. With this patient population it would be important to utilize all available resources and be prepared to

SELF ASSESSMENT OF NURSING PRACTICE STANDARDS change the care plan depending on condition. The plan of care must also include the hospital standards and address or meet expected core or quality measure outcomes. Although competent in this standard, I am conscious of my strengths and weaknesses in everyday practice and must continue to make a conscious effort to ensure continuity of patient care and be sure all team members are utilized appropriately in the plan. Standard 5: Implementation The AACN (2008) standard of implementation states, The nurse caring for the acutely

and critically ill patient implements the plan, coordinates care delivery, and employs strategies to promote health and a safe environment (p. 12). I believe my competency in the standard of implementation is confirmed with my critical care practice. Implementing a plan of care includes delivering the prescribed nursing or medical interventions in a way that promotes the patients optimal health status (AACN, 2008). In practice as an ICU nurse life threatening situations are not uncommon. Documentation of the progress and implementation of interventions can change rapidly and must be based on the patients ability to participate. Nurses in critical care must practice patience and understand body systems and tolerance to activity. Families must be integrated in carrying out interventions whenever possible, especially if patients will need care at home after discharge. In the critical care unit collaboration and coordination with other staff is critical. An example is implementation of respiratory care, treatments or interventions. The respiratory therapist is a critical team member when carrying out nursing respiratory interventions. For example, if a critically ill patient requires transport to diagnostic testing, I coordinate care with the respiratory team early in the shift and prepare emergency drugs prior to the departure from the unit. Providing a safe proactive environment will promote the best outcome possible from any interventions implemented or emergency care

SELF ASSESSMENT OF NURSING PRACTICE STANDARDS needed in response to a change in condition. Implementation of strategies is dependent on skill and on the quality of the assessment, diagnosis, plan of care developed, and patient tolerance. Standard 6: Evaluation The AACN (2008) standard of evaluation states, The nurse caring for the acutely and critically ill patient evaluates progress toward attaining outcomes (p. 13). I believe I am competent in this standard because I utilize all the resources available to me in the ICU to document and appropriately adjust the plan of care to meet the patient needs, as they progress to their prescribed goals, on a continuous basis. I utilize evidence based techniques in my practice and communicate with peers and patient families. Being able to evaluate the interventions implemented based on assessment and diagnosis is imperative in critical care nursing. For example, if appropriate nursing interventions, such as position changes or drug administration does not produce optimal or expected results, the plan must be modified or other interventions must be attempted in order to produce the desired outcome. In addition I am very cognizant of my accuracy of documentation and make every effort to communication all pertinent data to peers to maintain consistency of patient progress toward expected outcomes. Professional Development Plan Developing a plan for continuous professional growth and personal advancement is important to promote optimal patient outcomes and advance the profession of nursing. In adherence to the Code of Ethics for Nurses, many provisions dictate constant personal and professional growth, and support for the organization in which one works (American Nurses

Association [ANA], 2001). A personal development plan will allow for evaluation of the growth and advancement of my nursing career and professional practice. I am competent in all six critical care standards as set forth by the AACN (2008), but I will continue to advance my

SELF ASSESSMENT OF NURSING PRACTICE STANDARDS education, learn about and integrate evidence into my practice, utilize my mentor and other

available resources, seek certifications in my specialty, and constantly reevaluate the needs of the workplace and environment around me. Goals are presented below and a time line of attainment, as well as an avenue for evaluation of progress. Assessment The continuous development of assessment skills with critical care patients is imperative to produce optimal outcomes. Increased skill in patient assessment comes with deeper understanding gained through education. Goals to maintain and further my competency in this standard are to advance my college degree to a masters in nursing with an emphasis on education. The necessary steps needed to carry out this goal are to complete my Bachelor of Science in Nursing (BSN) and advance to completion of the Master of Science in Nursing (MSN). The action plan to obtain these goals will be to attend college, utilize employee tuition reimbursement, and obtain my BSN degree in May 2013, as evidenced by satisfactory completion of curriculum and securement of a diploma. After acceptance and registration, in the fall of 2013 I will begin the MSN program at Ferris State University and complete my MSN by fall 2016, also as evidenced by satisfactory completion of curriculum and securement of a diploma. Evaluation of progress toward these goals will be advancement in the degree program with grades higher than 3.0 on a 4.0 scale. All outcomes will be measured on an education plan spreadsheet and progress will be tracked and reevaluated quarterly. Diagnosis To maintain and improve competence in the standard of diagnosis I will seek to learn more about my specialty and human body systems. This goal will be achieved by attending and

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teaching at my unit based critical care skills lab and sitting for my Critical Care Registered Nurse (CCRN) specialty certification. Voluntary participation in critical care skills lab as an educator will occur in February 2013. Attainment of this goal will be evidenced by acceptance in to the unit based training program. The action plan is to contact the critical care educator and enter my name on the roster. Evaluation as progress toward this goal is to maintain contact with the critical care educator and attend all training sessions as scheduled. In order to obtain my CCRN certification I will study and register to take the exam. The action plan to take the exam is to study and apply to take the test. I am now in the process of studying for the exam and will submit my paperwork for a date to test in June 2013. I will obtain certification in July 2013. This will be evidenced by the certification document of which I will maintain by completing the appropriate continuing education credits. To evaluate the progress toward this goal I have enrolled in an official CCRN study group. This group has monthly meetings and webinars to track progress of participants. I will attend 100% of the meetings. Outcomes Identification To maintain and advance my competency in patient outcome identification my goals are to increase my knowledge of evidence based practices and participate in research. To attain these goals I will attend 100% of the monthly meetings of my organizations evidence based practice (EBP) council, of which I have been a member for three years. The action plan to attain this goal is to keep abreast of the meeting times and participate in discussions. Attainment of this goal will be evidenced by 100% attendance in the council attendance roll and meetings will be scheduled on my outlook calendar. Since I am already a member of the committee, evaluation of progress toward this goal will be to check for meeting times daily and be conscious of scheduling meetings or work hours around the EBP council meeting dates and times.

SELF ASSESSMENT OF NURSING PRACTICE STANDARDS To attain the goal of research participation I will contact our research department and request placement on the progressive mobility research team by November 21, 2012. By

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attaining this goal I will be participating in the discovery of best practice standards. The action plan for attaining this goal is to accept and attend 100% of the weekly meetings, participate in the patient consent process, and take the online certification through the research department to be a data collector. I will complete the certification by December 1, 2012. This specific research study will start baseline data collection December 12, 2012 and start enrolling patients in February 2013. The research project is 18 months long. Evaluation of progress toward this goal of participation in a research study will be clear, and each step will be documented on an electronic timeline and evaluated weekly. Planning To maintain and advance my competency in the standard of planning my goal is to develop a plan to promote compliance of attendance by team members during multidisciplinary rounds of patients in the critical care unit. These rounds help develop the plan of care for patients but at times tend to be poorly attended. To better serve the patient, 100% inclusion of all team members during rounds will be encouraged to promote continuity of care and consistent evaluation of all diagnoses and goals set for each patient. The action plan to attain this goal will be to meet with the critical care unit action council in December 2012 and propose a plan to work with all provider and ancillary departments to standardize start times to rounds and demand 100% representation. Next, would be to secure a spot on the January 2013 ICU physician section meeting to propose the plan. Ideally, the proposed plan will go into effect by February 2013. Evaluation of the progress toward this goal will be evidenced by accepted meetings from

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the unit action council and the ICU physician scheduling representative. An electronic timeline will be kept and updated weekly to document progress and team member responses. Implementation A goal to improve my practice and maintain my competency in the standard of implementation is to promote and increase the quality and detail of my patients electronic interventions record by December 2013. Precise documentation is critical to telling the story of the patient. Increased quality of documentation on this record will promote optimal patient outcomes and consistency of care. The action plan to implement this practice change will start immediately and will include immediate development of a specific outline I will use to accomplish the detailed charting. Evaluation will be ongoing for this goal. For the first two weeks I will use electronic reminders to promote this increase in quality of charting. I will chart 100% of the time and address every implemented intervention according to the plan of care. Evaluation The ability to evaluate interventions and patient responses is critical. Patient responses to interventions are continually changing and often require a change in the direction of care based on evaluation. Goals to promote my professional practice and maintain my competency in this AACN standard is to renew my membership in the American Association of Critical Care Nurses (AACN) which provides a subscription to an evidence based nursing journal, of which I will read at least two articles each month. The goal of AACN membership will be attained by paying online for renewal of my recently expired AACN membership by December 2013. Reading articles each month will begin in January 2013. Evaluation of the progress toward these goals will be by placing a date on my electronic bill calendar to pay for the subscription, and

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attainment of the goal of reading articles will be accomplished by setting electronic reminders to obtain and read articles. Conclusion I am dedicated to my practice and the profession of nursing. I will continue to reevaluate my practices and change as needed in order to maintain competency with practice standards and promote quality patient outcomes. I feel I have reached a high level of competency with all the standards of practice for critical care nurses, but I also realize that learning is ongoing. More education will allow me to meet my goals in life, advance my profession and develop my practice and my leadership skills. I have enjoyed examining and comparing my nursing practice to the standards. Outlining all the aspects of my practice gives me clarity. I feel I am in line and adhering to national standards. It will take hard work, but I will remain focused and cohesive with my patients and colleagues and strive to maintain my established professional standards. I will use the autonomy afforded me to maintain the highest degree of integrity to support my institution, my profession and my patients.

SELF ASSESSMENT OF NURSING PRACTICE STANDARDS References

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American Association of Critical Care Nurses [AACN]. (2008). AACN Scope and standards for acute and critical care nursing practice. Aliso Viejo, CA: Author American Nurses Association [ANA]. (2001). Code of ethics for nurses with interpretive statements. Retrieved from http://nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/C ode-of-Ethics.pdf

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CHECKLIST FOR SUBMITTING PAPERS CHECK DATE, TIME, & INITIAL
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PROOFREAD FOR: APA ISSUES 1. Page Numbers: Did you number your pages using the automatic functions of your Word program? [p. 230 and example on p. 40)] 2. Running head: Does the Running head: have a small h? Is it on every page? Is it less than 50 spaces total? Is the title of the Running head in all caps? Is it 1/2 from the top of your title page? (Should be a few words from the title of your paper). [p. 229 and example on p. 40] 3. Abstract: Make sure your abstract begins on a new page. Is there a label of Abstract and it is centered at the top of the page? Is it a single paragraph? Is the paragraph flush with the margin without an indentation? Is your abstract a summary of your entire paper? Remember it is not an introduction to your paper. Someone should be able to read the abstract and know what to find in your paper. [p. 25 and example on p. 41] 4. Introduction: Did you repeat the title of your paper on your first page of content? Do not use Introduction as a heading following the title. The first paragraph clearly implies the introduction and no heading is needed. [p. 27 and example on p. 42] 5. Margins: Did you leave 1 on all sides? [p. 229] 6. Double-spacing: Did you double-space throughout? No triple or extra spaces between sections or paragraphs except in special circumstances. This includes the reference page. [p. 229 and example on p. 40-59] 7. Line Length and Alignment: Did you use the flush-left style, and leave the right margin uneven, or ragged? [p. 229] 8. Paragraphs and Indentation: Did you indent the first line of every paragraph? See P. 229 for exceptions. 9. Spacing After Punctuation Marks: Did you space once at the end of separate parts of a reference and initials in a persons name? Do not space after periods in abbreviations. Space twice after punctuation marks at the end of a sentence. [p. 87-88] 10. Typeface: Did you use Times Roman 12-point font? [p. 228] 11. Abbreviation: Did you explain each abbreviation the first time you used it? [p. 106111] 12. Plagiarism: Cite all sources! If you say something that is not your original idea, it must be cited. You may be citing many timesthis is what you are supposed to be doing! [p. 170] 13. Direct Quote: A direct quote is exact words taken from another. An example with citation would look like this: The variables that impact the etiology and the human response to various disease states will be explored (Bell-Scriber, 2007, p. 1). Please note where the quotation marks are placed, where the final period is placed, no first name of author, and inclusion of page number, etc. Do all direct quotes look like this? [p. 170-172] 14. Quotes Over 40 Words: Did you make block quotes out of any direct quotes that are 40 words or longer? [p. 170-172] 15. Paraphrase: A paraphrase citation would look like this: Patients respond to illnesses in various ways depending on a number of factors that will be

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explored (Bell-Scriber, 2007). It may also look like this: Bell-Scriber (2007) found that [p. 171 and multiple examples in text on p. 40-59] For multiple references within the same paragraph see page 174. 16. Headings: Did you check your headings for proper levels? [p. 62-63].

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17. General Guidelines for References: A. Did you start the References on a new page? [p. 37] B. Did you cut and paste references on your reference page? If so, check to make sure they are in correct APA format. Often they are not and must be adapted. Make sure all fonts are the same. C. Is your reference list double spaced with hanging indents? [p. 37] PROOFREAD FOR GRAMMAR, SPELLING, PUNCTUATION, & STRUCTURE 18. Did you follow the assignment rubric? Did you make headings that address each major section? (Required to point out where you addressed each section.) 19. Watch for run-on or long, cumbersome sentences. Read it out loud without pausing unless punctuation is present. If you become breathless or it doesnt make sense, you need to rephrase or break the sentence into 2 or more smaller sentences. Did you do this? 20. Wordiness: check for the words that, and the. If not necessary, did you omit? 21. Conversational tone: Dont write as if you are talking to someone in a casual way. For example, Well so I couldnt believe nurses did such things! or I was in total shock over that. Did you stay in a formal/professional tone? 22. Avoid contractions. i.e. dont, cant, wont, etc. Did you spell these out? 23. Did you check to make sure there are no hyphens and broken words in the right margin? 24. Do not use etc. or "i.e." in formal writing unless in parenthesis. Did you check for improper use of etc. & i.e.? 25. Stay in subject agreement. When referring to 1 nurse, dont refer to the nurse as they or them. Also, in referring to a human, dont refer to the person as that, but rather who. For example: The nurse that gave the injection. Should be The nurse who gave the injection Did you check for subject agreement? 26. Dont refer to us, we, our, within the paperthis is not about you and me. Be clear in identifying. For example dont say Our profession uses empirical data to support . . Instead say The nursing profession uses empirical data.. 27. Did you check your sentences to make sure you did not end them with a preposition? For example, I witnessed activities that I was not happy with. Instead, I witnessed activities with which I was not happy. 28. Did you run a Spellcheck? Did you proofread in addition to running the Spellcheck? 29. Did you have other people read your paper? Did they find any areas confusing? 30. Did you include a summary or conclusion heading and section to wrap up your paper? 31. Does your paper have sentence fragments? Do you have complete sentences? 32. Did you check apostrophes for correct possessive use. Dont use apostrophes unless it is showing possession and then be sure it is in the correct location. The exception is with the word it. Its = it is. Its is possessive.

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Great paper Tami. Be sure to correct the red font and dbl check there are several periods not followed by 2 spaces. Sentence structure and wording all look good. You are a very good writer and always a pleasure to review your work- Kim
Signing below indicates you have proofread your paper for the errors in the checklist: Tamara Putney 11/12/12 ________________________________________________________DATE:________________ A peer needs to proofread your paper checking for errors in the listed areas and sign below: Kim Weigal 11/14/12 ________________________________________________________DATE:_______________