Proficiency 2
Table of Contents
Proficiency
This nurse participated in fire incident that occur on the unit, by evacuating patient to safe area, also try to go in to make sure there is no patient left on the unit and check the safety of all the staffs working that day, Assisted to transfer patient to another facility by coordinating care, among the staff as charge nurse.
DISTRUPTIVE BEHAVIOR: I was charge nurse by the help of other disciplinary team to de-escalate the patient behavior to maintain safety with other patient and staffs.
As charge nurse during rounding, I found the patient by the side of his bed laying unconscious, help and rapid responded called the patient situated and transfer to ED for further evaluation.
I helped patient found his belonging after left to another facility because there is changed in his status that lead to critical, patient recover and came back looking for his belonging this nurse, make call and able to locate patient belonging and patient was happy and said to this nurse” You are done so great for me, I never thought I would be able to find my belongings after several attempt with other staff.
This charge nurse utilize the staff because of shortage of staff when acity level was high for example 3 patient on 1:1 status, before the NOD was able to found help for us, in which the patient were safe and staff.
I worked on mental health unit for 2 years as Registered nurse.
Practice: Ms. Y is a Bachelor’s prepared registered nurse with….acute care nursing experience who utilizes the nursing process and evidenced based practice to care for patients
Demonstrates proficiency using the nursing process in providing care for clients with complex nursing care needs. Guides and directs others who provide care.
• Functions in the capacity of charge nurse on the night shift. As charge nurse duty ensures the smooth running of operations on the unit. Also delegates patients assignments by assigning patients to oncoming tours; coordinates new admissions by assigning rooms to new admissions and ensuring that orders are carried out; ensures team work on the shift, and addresses others issues arising in the course of the night.
Ethics: Identifies ethical issues in practice and takes appropriate action.
Takes appropriate action in identifying and serves as a resource for clients and staff in addressing ethical issues.
. On June 2016, I had a patient who was in pain due to orthopedic surgical procedure. During initial assessment, patient rated pain 10/10 and did not have any pain medication ordered. I called the on-call surgeon who directed me to call the attending surgeon. Every attempt to reach the attending surgeon failed. After several attempts, I called the on-call surgeon back and eventually got orders for pain medication. The patient threatened to leave and even attempted to get out of bed. I was able to calm him down and eventually obtained order for his pain medication. The patient was kept comfortable throughout the shift. The attending surgeon called in the morning and commended the nurse stating that he appreciates all the efforts made to ensure his patient was comfortable during the night.
Resource Utilization: Delegates care in a safe, efficient, and cost-effective manner. Assists clients in identifying and securing appropriate services.
• A patient who was discharged called the unit in June 2016, saying that the husband lost his driver’s license when they came for appointment and needed help finding it. I asked this patient the locations they had been while in the hospital. I called some places, and eventually, I called the pharmacy and found out the patient left the drivers license at the pharmacy. I got back to the patient and told them we found it, they were happy and relieved.
PROFESSIONAL DEVELOPMENT
Education/Career Development: Implements an ongoing educational plan to support own professional development.
• Currently, undertaking masters in Family Nurse Practitioner.
With the growing demands for clinicians in VHA and the ongoing proposal to recognize APRNS as full practice providers within VHA facilities, obtaining this degree would benefit the hospital in that it would provide more affordable care that is safe and of high quality to the men and women who have served; and also help alleviate provider shortages and ensuring access to services in high demand.
• June 2011, I attended a course titled “Diabetes Medications – Initiating, Advancing and Stopping for the Advanced Practice Nurse” on myVEHU. The course addressed common oral diabetic medications and insulins; and the safety issues associated with them, with an emphasis on patient safety. I have been able to incorporate knowledge gained into caring for diabetics on the unit and providing education on lifestyle management to keep their diabetes under control. For example, I had a patient who was on insulin and has been hypoglycemic in mornings for the past two days. After reviewing the chart, I placed a call to the MD prior to end of my shift and the patient’s AM insulin dosage was adjusted. The patient’s AM blood glucose was controlled in a timely manner as a result of this and this also led to a reduction in cost of hospitalization.
Performance: Conducts self-assessment of performance and identifies own learning needs. Assesses performance of others.
• Continually assesses my own practice and makes adjustment in practice as needed based on Evidenced-Based practice. Open to correction and constructive criticism.
• For example, I when I came here newly, I heard a patient complaining that she was given an intramuscular injection and that the nurse did not mark the site properly. I brought this to the attention of the clinical nurse leader. As a result, education was provided to all staff on the proper sites for intramuscular injections. This has enhanced knowledge about the area of concern, lead to client satisfaction, and also prevent complications that could arise from wrongful injection.
COLLABORATION
Collaboration: Refers to, consults with, and makes provision for continuity of care with other health care providers.
• In May 2016, on the night shift, I had a patient who developed nausea and vomiting, having greenish emesis. A call was made to the physician who came in during the night. The patient was taken to the OR the next day for surgery. The physician was impressed and wrote to the Director of Nursing about the episode. I received a commendation letter as a result of this action. This has improved the image of the unit and also promoted patient safety as the patient was saved from what could have been a sentinel event. I also educated staff on the use of SBAR to communicate with physicians.
Collegiality: Provides feedback regarding the practice of others to improve client care.
SCIENTIFIC INQUIRY
Quality of Care: Participates in established quality improvement studies and/or activities.
• Represents my unit at the Women Veterans Health Committee. Even though I worked the night shift, stayed to work as a volunteer at the VA Goes Red for Women event on Friday, Dec 5th, 2016. At the event, we served about 100 participants. I provided education to female veterans about the importance of being heart healthy. The outcome includes improved veteran’s health, health promotion and disease prevention; reduced cost of hospitalization related to cardiovascular disease.
Research: Uses a body of research to validate and/or change own professional practice.
• I use the SBAR in communicating with the providers when needing clarifications with patient orders or any issues arising in the course of my tour. On May 2016, I provided education to colleagues on the use of SBAR in calling physicians and delivering clear messages to promote quality of care and patient safety. Evidenced-based practice shows that use of SBAR enhances provider/nurses communication in that it aids in providing accurate and concise information about a patients care, treatments, current condition, and recent or anticipated changes. Incorporating this into patient care has proved to be an effective technique that can be used to clarify and streamline information exchanges between doctors and nurses, thereby reducing the chance of patient harm due to disorganized and unclear communication.
GOALS:
Short Term Goal
Complete my master’s program in FNP in 2017.
Long-Term Goal
Certification in mental health nursing
Doctorate degree in Family Nurse Practitioner
PRACTICE
Practice: Below are some of practices I believe I do.
She is a registered staff nurse on 4 East, a Medical Surgical Unit with Telemetry. She practices using the nursing process which she utilizes in her every day work and maintains optimum standards of care for our Veterans with a wide variety of health problems. She has demonstrated the ability to care for veterans with integrity, honesty and accountability. While providing care she also provides patient education and therapies geared towards control, management, prevention of infections and complications. For example: When at the bedside discuses with the patient about their blood glucose levels and what insulin or medications they will be receiving. Providing diabetic teaching by explaining diet requirements and how to take medications appropriately. She maintains a professional attitude toward veterans and staff members. She provides privacy during care and maintain patient confidentiality when speaking about patient concerns and conditions. She is mindful to always be respectful to veterans and peers.
As a RN on this unit here are some of her practices in the unit: Demonstrate the ability to function effectively in the charge nurse and leader roles. Utilize effective problem –solving skills, seeking confirmation from co-workers and supervisors when confronted with difficult situations. Readily identified a potential critical situation, taking the appropriate actions to provide quality positive patient outcomes. Her professional practice is patient focused, am consistently advocating for my patients and striving to maintain high standards and patients right. As charge nurse, makes assignment in a manner that reflects optimum use of available staff while prioritizing patient cares and needs. Changing assignments per the unit acuity level and work load. Promote planning and continuity of care through developing an individualized interdisciplinary plan of care in collaboration with the patient, family and the health care team
******* She applies the nursing process to improve care, and manages complex care. She showed this in evaluation of a general surgery patient s/p foot surgery with long post-operative course, initially post operatively the patient was on Telemetry, but after 3 days the doctor discontinued monitoring as patient had no events (history of MI); an EKG was obtained before discontinuation of telemetry which was normal sinus rhythm — this was performed on day shift. Working a PM shift on the telemetry unit and had worked with the patient previously the past few days determined something was ‘off’, with her rhythm couldn’t put her finger on it which warranted continued observations/assessment. Her thorough assessment and intuition determined the patient had a new onset of atrial fibrillation. Doctor was notified and Patient was started on cardiac meds, and converted back to normal sinus rhythm within 24 hours of my assessment. Her assessment and subsequent interventions resulted in prompt treatment of atrial fibrillation, and resulted in saving the patient’s life and probably not having to be anti-coagulated for the rest of his life.
Ethics: Supports and enhances client self-determination. Serves as a resource for client and staff in addressing ethical issues.
Provide Examples and Measurable Outcomes Demonstrating How Dimension/Criteria Met:
This nurse serves as resource to patients, providers, families, and other staff when ethical issues arise: She provides ethical resource information to patients, families and staff, adhere to VAMC ethics and compliance standard in work activities. She supports and enhance patient’s self-determination, provide accurate information needed for patients to understand the implications of Advance Directives, informed consent and Patient’s Bill of Rights. She assists staff and new Medical students to comply with the HIPPA regulations on patient confidentiality; reminding them to promptly Log off computer/system when two steps aware, shred un-needed papers with patient’s identifiable information, not seek to know information of the patients not under direct care. Putting patient first good knowledge of ethical issues and to provide accurate information to patient. She treats patients and family with respect. Proactively, respect patient self-dignity, space and privacy without compromising standard of care given. She promptly encourages others to provide privacy when changing linen and during hygiene activities. She assists providers, patients and families to comply with informed consent for procedure.
Resource Utilization: Identifies and assesses resource utilization and safety issues, taking appropriate action.
Provide Examples and Measurable Outcomes Demonstrating How Dimension/Criteria Met:
This nurse effectively provides care to patients and minimizes waste without compromising patient positive outcome. She makes safety rounds as a charge nurse and uses sound judgement to identify malfunctioning equipment and take prompt actions to contact engineering department for repairs and replacement. She demonstrates the ability to prioritize and coordinate patient care by completing assignment within the scheduled hours of work to decrease overtime. She considers factors related to safety, effectiveness and cost in delivering care. She possesses effective leadership skills in emergent situations and knows how to adjust staff assignments to meet the needs. She is able to assess unit activity and patient acuity to assign staff appropriately.
PROFESSIONAL DEVELOPMENT
Education/Career Development: Acquires knowledge and skills to maintain expertise in area of practice. Participates in educational activities to improve Clinical knowledge and enhance role performance.
Provide Examples and Measurable Outcomes Demonstrating How Dimension/Criteria Met:
She personally develops and pursues educational plans to help maintain and improve knowledge in her specialized area of professional practice. She currently holds a BSN and has almost completed her MSM. She maintains current ACLS and CPR certifications. She effectively attends continuing educational program; reviewing current literatures and research findings that are relevant to her present job skill and competence development. She assumes responsibility for completing mandatory education requirements on the TMS learning program, complete annual mandatory training on time. She attends and participates in skill fares, participates on in-services, seminars and conferences for skill development.
Performance: Evaluates practice of self and others using professional standards, relevant statutes, and regulations. Takes action to improve performance. Examples and Measurable Outcomes Demonstrating How Dimension/Criteria Met:
This nurse does not require supervision to solve routine clinical problems. She attends seminars, read current literatures, review current research findings for self-professional improvement. She utilizes close assessment findings to identify areas of patient/family knowledge deficit, initiate educational plans to meet patient care needs. She is always on the lookout for actual or potential problems and intervenes promptly; making sure that intubated patients and those on tube feeding have HOB elevated up to 30 degrees to prevent aspiration. She anticipates changes, prioritize, initiate and modify her work to accommodate staff and patient needs, she is flexible and readily available for pulling to other departs within organization in other to cover staff needs. She attends continuing education program, review new policies and new regulations and applies new changes as needed into practice. She practices OSHA sanitation act and JACHO privacy act in her nursing care. She adheres to current procedures for patient safety, observe universal precautions and effectively handle hazardous material and equipment associated with my job. Demonstrate knowledge of occurrence reporting system and use system to report potential patient safety issues, such as fall and near incidents.
Collaboration/Collegiality: Educates colleagues and/or students and serves as a preceptor and/or mentor.
She encourages collaboration and teamwork; She works effectively with others and encourage cooperation among staff. She communicates effectively and professionally with internal and external customers. A team approach is the best way to care for patients. For example: I) Encouraging our veterans to use the resources available to them such as transportation, and social services for assistance. II). Encouraging veterans / family members to use correct equipment when entering isolation rooms and using disposal equipment to help prevent infection. Listening to patient complaints and coming up with resolutions. These are to encourage the patient to get involve with their own health care.
SCIENTIFIC INQUIRY
Quality of Care: Initiates/participates in quality improvement activities that result in approved outcomes.
Research: Uses a body of research to validate and/or change work group practice.
She uses scientific based evidence for practice in her profession. She observes diverse methodologies which focus on the understanding and relieve of symptoms of acute and chronic illness. Her eight years as a nurse with five years at Hampton VA has helped her to constantly improve her critical thinking and problem solving skills. She effectively uses traditional approaches in controlling pain, behavioral activities and anxiety-induced confrontations that did not require utilizing medications such as dimming the light, talking to patient in a soft tone of voice, reposition them to make them comfortable. She makes sure that she is compliant with HVAMC’s policy and performance initiatives.
GOALS:
Her goal is to ensure proper care of our veterans and use optimum standards of care.
Complete her MSN and enhance her nursing knowledge and skills so that she can go on to provide more efficient care for her patients.
She will continue to endeavor hard to do her very best in providing excellent care to our Veterans and to be a constant asset in this organization.
PRACTICE
Ms. O is a registered nurse on the inpatient psychiatric unit for (35-37) acute / rapid stabilization of (MH/BS), assigned to evening tour of duty, coed patients with diversified backgrounds at different developmental stages. The patient’s clinical presentation typically presents as acute depression, bipolar, schizophrenia, anxiety, substance abuse problems, and PTSD including psychosocial issues. Ms. O functions as charge nurse continue to demonstrate leadership, greater accountability, and knowledge in the delivery and application of her nursing practice, critical thinking, planning, prioritizing, collaboration, and coordination of skills while guiding, and directing (13-15) staffs in the provision of direct quality nursing care with minimal supervision.
Practice: Applies the nursing process to systems or processes at the unit/team/work group level to improve care. Demonstrates leadership by
Involving others in improving care.
Ms. O applied nursing process to the provision of patient care in order to improve care outcome. Ms. O demonstrated using nursing process in the following ways: completes and implements initial assessment, reevaluation with follow-up based on the patients presenting individual clinical presentation, provides education upon assessment of patient/family’s educational needs, and team for a safe discharge plan. She participates to address the overall holistic function and maintenance of the Veteran’s physical, emotional, and social environment toward the goals of achieving physical survival, self-determination, and autonomous community functioning because of (assessment, planning, monitoring, advocacy, and implementation) contributing to the Veterans full potential. Ms. Oke assist to safely discharge approximately (25-30) patients per week and this discharge performance contributes to helping reduce the length of stay (LOS) as indicated from fy 2014, from (12.3-7.56) days per utilization management. During shift reports as Charge nurse, assist staff with focusing on problem areas unique for the patient’s treatment, behavior, or psychosocial well-being. Monitors and implements crisis intervention for those patients having active suicidal, homicidal or aggressive behavior because of diminishing mental and physical conditions. Implementation of one to one observation, medication administration, or rapid response. Provides goal/wrap-up groups and informal health education in the areas of medication compliance, suicide, smoking, and alcohol cessation while inpatient and upon discharge to patient and family members when applicable. She is competent in administering medications like insulin, and PRN effectiveness f/u within (60-120 minutes), monitors adverse reactions and critical syndromes (Extrapyramidal side effects, Tardive dyskinesia, and Neuroleptic malignant syndrome) associated with this class and use of antipsychotic medications for sustained quality clinical care and safety. Provides leadership during response to fire drills, and disaster with the goal of maintaining safety for patients and staff while meeting timeframe activation for response to alarm. Maintain infection control and procedures (PPE, hand washing, etc…) Her manner of practice is sensitive to and respectively for diversity of patients and staff in a non-judgmental way by promoting the medical centers mission, vision, and core values “I CARE” while contributing to the nursing profession with compassion and respect for the dignity, worth, and uniqueness of all individuals without regard to social, political, economic standings, or healthcare problems. Regularly is complimented by mental health patients for her care provided to them while hospitalized. As a result of her practice, sustained quality patient care has been maintained and or improved while applying the ANA code of Ethics, Nursing process, and VHA Nursing policies to guide her professional practice. Reflecting a culture of values: Integrity, Commitment, Advocacy, Respect, and Excellence; “I CARE.”
Ethics: Supports and enhances client self-determination. Serves as a resource for client and staff in addressing ethical issues. For example, serves as a resource for Veterans and staff in addressing ethical issues. Advocates on behalf of the patient in support of self-determination and diversity of all patients, including staff. Continuously maintains patient privacy and HIPPA policy during visitation, phone calls with family, electronic medical records (EMR) use, and with others as a need to know basis, including staff. Routinely ensures MHBS patients are maintaining appropriate distance away from others while in line for medication administration for patient privacy sustainment per VISN directive.
Resource Utilization: Identifies and assesses resource utilization and safety issues, taking appropriate action. She demonstrates her ability to report safety hazards, incident reports, staff injuries, and equipment failure or request for new equipment from her supervisor. Initiates a compatible working relation with other services such as (Biomedical, LIDS, Environmental Services, IRM, Linen/Clothing room, Maintenance, Units, Departments, VA Police, and Dietary) in order to obtain needed resources, supplies, services, and repairs for best possible patient care delivery. She collaborates with AOD and ER for admissions, call pharmacy to clarify medications for patients, notify nurse managers and NOD if any incident or for staff issues. Ms. O collaborate with peers to avoid spilling and to complete workload in a safe and timely manner.
PROFESSIONAL DEVELOPMENT
Development Education/Career: Acquires knowledge and skills to maintain expertise in area of practice. Participates in educational activities to improve clinical knowledge and enhance role performance. She completed her BSN in 2018. She continuously accountable for meeting the qualification standards and functional statements of assigned grade and Basic Life Support (BLS) certification, has maintained all annual education requirements for medical center and Nursing employees. Ms. Oke guide and assist newly hired Registered Nurse (RN), Licensed Practical Nurses (LPN) having no previous knowledge or employment experience within VHA system.
Performance: Evaluates practice of self and others using professional standards, relevant statutes, and regulations. Takes action to improve performance. Ms. Oke assess and maintain the educational need for her position. She is up to-date with the TMS educational requirements and competencies needed to perform her duties. Her nursing license is current for the practice. Ms. Oke work ethics is an exemplary, stay away from excessive call- out. She advice and recommended staff to avoid excessive call-outs. She participates in the training of new staff education and understanding of 2-North unit standard. Ms. Oke oriented staff that comes from other units to work in 2 – North and actively involved in evaluating unit practices against the standards set by JACHO OSHA. She conducts teaching group of patient’s on Diabetes. She plays a huge role in calculating and graphing how well 2-North unit follow-up in PRN effectiveness when compared to benchmark and the rest of the Hampton VAMC and consistently performs draw note for continuity of care, communication, and assess for high risk for falls patients, documents in CWAD.
COLLABORATION
Collaboration: Uses group process to identify, analyze, and resolve care problems. Ms. Oke routinely communicates anticipated discharges and transfers of patients with Emergency Psychiatric Nurse attempting to admit MH/BS patients to the units, whom have been waiting in ED under virtual bed status. This lead to Ms. Oke partnering with unit Environmental staff to develop a back-up plan for improved communication, bed allocation, and cleaning called “To be cleaned,” (TBC) when electronic bed board system is inoperable or as a second layer to ensure timeliness of room preparation and assignment to maintain seamless ACCESS TO CARE. She delegates tasks appropriately and per level for NA’s, LPN’s and as well as RN’s. Example RN’s performs the first hour rounds to ensure no patient is on the floor or having behavior or medical issues. As charge nurse on night tour, Ms. Oke performs research to complete what we call the AM Worksheet. The AM worksheet has in it names of resident patients who are scheduled for bloodwork to be drawn, who have urine to be collected, who have withdrawal scale assessment.
Collegiality: Educates colleagues and/or students and serves as a preceptor and/or mentor. Ms. Oke routinely, provides role modeling, educational learning and guidance to nursing students when performing clinical rotation on the (MH/BS) unit regarding specific practices unique to Mental Health Nursing, such as use of coping skills, designation of a temporary detainment order (TDO) vs. involuntary committed (IC), application of restraints, signs and symptoms of Alcohol withdrawals with use of Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale, for score aggregation and management with benzodiazepines. Consistently, informally in-services medication nurses of proper protocol and procedures when verifying insulin to uphold infection control standards and application safety.
SCIENTIFIC INQUIRY
Quality of Care: Initiates/participates in quality improvement activities that result in approved outcomes. Quality of Care:
Ms. Oke uses knowledge to validate or change work group practices as appropriate, such as VHA National Pain Management Strategy and TJC standards; assessing for pain with vital signs as the fifth assessment and completion of the comprehensive pain assessments for monitoring and improvement in outcomes of pain treatment in the VHA system.
Research: Uses a body of research to validate and/or change work group practice. Ms. Oke given the escalating concerns in healthcare regarding accountability and responsibility for providing high-quality patient care and safety, removal of the behavior is crucial. Interventional educational awareness and effective zero-tolerance policies to deflect the disruptive events. The technique uses pre-written responses to the most common distruptive behaviors, while ultimately improving staff relations and who have blood sugar assessment, who have stool collection for occult test, who are on blood pressure medications for vital assessments, and who have special procedures such as NPO, I & O.
Ms. Oke demonstrates her ability to report safety hazards, incident reports, staff injuries, and equipment failure or request for new equipment from her supervisor. Initiates a compatible working relation with other services such as (Biomedical, LIDS, Environmental Services, IRM, Linen/Clothing room, Maintenance, Units, Departments, VA Police, and Dietary) to obtain needed resources, supplies, services, and repairs for best possible patient care delivery. She collaborates with AOD and ER for admissions, call pharmacy to clarify medications for patients, notify nurse managers and NOD if any incident or for staff issues. Ms. Oke collaborate with peers to avoid spilling and to complete workload in a safe and timely manner.
Goals
Ms. Oke achieve her BSN in October 2018. She is in school for her master program in Nurse Practitioner at Walden University. She plans to get certify in Mental Health Board certification soon. Ms. Oke obtain mandated CEU requirements for Registered Nurse for Virginia renewal.
