Running head: A SELF-ASSESSMENT

American Nurses Association Standards of Practice & Code of Ethics: A Self-Assessment Dana Leigh Knoll Ferris State University

A SELF-ASSESSMENT Abstract

The American Nurses Association (ANA) has developed guidelines for professional nursing practice and ethics. These guidelines were established as a measure of professional competency to ensure safe and quality patient care. The aim of this paper is to evaluate my own personal progression towards meeting the fifteen standards of practice and nine ethical provisions. I will define each standard and provision and then provide evidence for how I have met them through classroom education, simulation or clinical practice. For each standard or provision that I have not yet met, I will develop a plan for continuing professional growth and development. It is through self-assessment that I am able to identify my strengths and weaknesses as they relate to my future career as a registered nurse.

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American Nurses Association Scope & Standards of Practice: A Self-Assessment The ANA published Nursing Scope and Standards of Practice (2010) as a guide for nurses to base their clinical practice. According to the ANA, all registered nurses, regardless of role, population, or specialty, are expected to perform [the standards] competently (2010, p. 31). Similarly, the ANAs Code of Ethics for Nurses (2001) describes the ethical standard by which every nurse should base ethical decision-making in practice. The code of ethics does not spell out ethical dilemmas, but instead provides a framework that nurses can apply to a myriad of ethical dilemmas that may be faced in practice. Both of these documents are the standard for nurses to measure themselves against. Adherence to the standards of practice and code of ethics are the sign of a truly competent, safe and effective nurse. Due to the evolving nature of nursing as a profession, the standards, too, are subject to change. It is the duty of all nurses to continually strive for professional growth and development to ensure safe nursing care. As a student nurse, it is important for me to measure my current body of knowledge and clinical skill against these professional standards to determine my preparedness for graduation and subsequent professional practice. Standards of Professional Nursing Practice & Performance Assessment Assessment is the first standard of practice and also the first step taken by a nurse in working with all patients. The ANA stipulates that to fulfill the standard of assessment, the nurse must collect comprehensive data pertinent to the healthcare consumers health and/or the situation (2010, p. 32). An assessment should be holistic and individualized, considering the patient as a unique person with unique preferences and needs. An important aspect of assessment is the documentation of the information found. Patient care is typically performed by

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an interdisciplinary team, thus relevant assessment data should be retrievable for other team members to access (ANA, 2010). From classroom to clinical setting, I have performed a number of assessments, both general and specialized. While practicing on an orthopedic floor I was tasked with performing frequent neurovascular assessments in addition to a full assessment. During new admission assessments I have been tasked with assessing not only the physical symptoms of a patient but also the possible emotional, psychosocial and interpersonal symptoms of a patient and his/or her family. All findings from my assessments are documented using PowerChart and assessment findings that are of a concern are promptly reported to the patients RN and/or physician as appropriate. Diagnosis The second standard, diagnosis, requires that the nurse analyzes the assessment data to determine the diagnoses or the issues (ANA, 2010, p.34). Nursing diagnoses are different from medical diagnoses and address the patient holistically. The aforementioned assessment skills are vital to identifying important digressions from the patients normal. Once a diagnosis has been identified, it is the duty of the RN to develop a care plan to address the diagnosis, and share findings with other healthcare providers as appropriate. My four previous semesters have prepared me for diagnosis and care plans with copious amounts of case studies, many of which shaped my skills for identifying the needs of my patients. Now that I am in my fifth semester of nursing school, I have been tasked with developing my own care plan for patients in clinical practice. During my psychiatric health clinical rotation, I was assigned a patient to assess and later develop a plan of care, which was then evaluated by an RN for completeness and applicability to my patient.

A SELF-ASSESSMENT Outcomes Identification

The third standard, outcomes identification, stipulates that the nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation (ANA, 2010, p. 35). To determine outcomes that are relevant and appropriate for the patient as an individual, the standards of assessment and diagnosis must be adequately performed and met. Good outcomes utilize the patient and the care team, consider risks and benefits, are culturally and ethically appropriate, are measurable and assist in continuity of care (ANA, 2010). As a part of developing a plan of care I must also develop outcomes, or goals, for the patient. When developing goals I know that they need to be SMART goals, or specific, measurable, attainable, relevant and time-bound. For example, a patient I have cared for had a sacral pressure ulcer. A priority diagnosis was impaired skin integrity, and one of the outcomes was to prevent formation of new pressure ulcers during the current admission. This outcome fits all of the criteria for a SMART goal and is also specific to the patients current health condition. Planning Planning is standard four and states that the nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes (ANA, 2010, p. 36). Planning requires the nurse to identify the outcomes detailed in standard three (Outcomes Identification) and create steps that will bring the patient closer to outcome completion. Strategies should be developed in partnership with the patient, patients family and care team, as appropriate. The plans should promote health, prevent illness and suffering and be based on science and evidence-based research. If I consider my patient from the previous example, I needed to plan strategies with the goal of preventing formation of new pressure ulcers. The strategies that I developed with the

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registered nurse and with the patient were frequent turning and positional changes, utilization of a pressure redistribution bed, floating heels, and daily bed baths to monitor and promote skin integrity. As a student nurse in my fifth semester I am just beginning to develop care plans in the clinical setting, so it is important for me to constantly strive to improve this skill. Collaborating closely with my nurse preceptor and making use of my nursing diagnosis handbook will help me to improve my care plans. Implementation Implementation is the fifth standard and it is simply the responsibility of the nurse to carry out the plan of care (ANA, 2010, p. 38). This particular standard consists of several sub standards that are important parts of implementing a plan of care. These include: Coordination of care, health teaching and health promotion (ANA, 2010, p. 40-41). Coordination of care requires the nurse to coordinate care delivery by organizing and managing the different components of a care plan (ANA, 2010, p. 40). The nurse should be the patients advocate so that all care provided by the interdisciplinary team is appropriate. Health teaching and health promotion requires the nurse to utilize strategies to maximize health and safety through teaching the patient and his or her family and care providers (ANA, 2010, p. 41). I think I have fulfilled the standard of implementation. I help to carry out plans of care with all of my patients in the clinical setting. Tasks such as scheduled turning, ambulation, and wound care are all strategies prescribed by a plan of care. I have helped to coordinate care by receiving and giving report to other care providers. One particular patient was a resident at a neurological rehab facility. One of his caretakers was present with him in the hospital and I worked with the caretaker so that he was aware of our plan of care and would be better able to care for the patient once he returned to the rehab facility. I satisfy the standard of health teacher

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and health promotion with each of my patients with education. At Munson Medical Center the charting system, PowerChart, prompts the nurse to perform patient education during each shift. Evaluation The sixth standard, evaluation, involves the nurse evaluating the patients progression towards completion of the previously determined outcomes (ANA, 2010, p. 45). The nurse should be constantly assessing the patient and evaluating the effectiveness of the care plan in propelling the patient towards outcome completion and discharge. Input should be gathered from the patient as well as the care team so that changes can be made if necessary. I practice evaluation with each of my patients in the clinical setting. In many of my patients, pain is a major issue that may complicate healing and recovery. I evaluate pain levels for these patients frequently, treat them with pharmacological and non-pharmacological interventions, and re-evaluate to determine the effectiveness of resolving the pain. Successful management of pain often allows the patient to focus on his or her other medical needs. Ethics Ethics is the seventh standard of professional nursing practice and simply put, calls for the nurse to practice ethically (ANA, 2010, p. 47). A document, into which I will go into more detail later in this self-assessment, which specifies the guidelines to ethical practice, is the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001). An ethical nurse should use this document to guide his or her clinical practice. Some values addressed in the ANAs code of ethics are patient autonomy, dignity, and confidentiality. Already in my short career as a nursing student I have come face-to-face with an issue regarding confidentiality. Munson Medical Center (MMC) is located in Traverse City, MI, just 20 minutes south of my hometown, Elk Rapids, MI. MMC is the areas only hospital so many

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people from Elk Rapids seek medical care in Traverse City. After seeing the name of a family friend on the patient list, I alerted my clinical instructor so that I was not assigned this patient. During my next visit home I was asked about the condition of the aforementioned friend. I had to let the inquirer know that I was not able to divulge any personal information. Education The standard of education states, the registered nurse attains knowledge and competence that reflects current nursing practice (ANA, 2010, p. 49). Nurses are required to obtain continuing education units to maintain their licensure. Nurses should be continually seeking new and current information, and evaluating current educational needs. I am currently in the process of fulfilling this standard. As a nursing student my time is spent on learning the skills and knowledge necessary to be a safe and effective nurse. In many of my classes I am required to find new evidence-based research to share with my classmates and in the clinical setting my nurse preceptors allow me to practice new skills. Professional Development Goals. Although there will never be a point at which I cease my education, my formal nursing education will be completed in May of 2014. At this time I will be prepared to competently perform the necessary duties of a registered nurse. To ensure that this goal is achieved I will continue to devote much of my time to my course work and work with my clinical instructors to determine areas that require improvement. Evidence-Based Practice and Research Evidence-Based practice and research is the ninth standard and it requires the nurse to utilize new and current research findings in his or her clinical practice (ANA, 2010, p. 51). The nurse should not only implement change according to evidence-based research, but also share with colleagues about new research (ANA, 2010).

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I have learned that being capable of evaluating evidence-based research is of the utmost importance in guiding patient care. In many of my classes in nursing school I have written papers based on evidence-based research. Some of the topics have included catheter-acquired urinary tract infections, restraint and seclusion use in mental health facilities, and assessment techniques for liver palpation. I think it is also important to make note that a nurse should not just implement a new practice because he or she read a research article. It is necessary to follow facility-specific policies, and if a new evidence-based practice seems promising, to present it to the appropriate managers so that policy change may be initiated. Quality of Practice The tenth standard requires the nurse to contribute to the quality of nursing practice (ANA, 2010, p. 52). The nurse can showcase quality of nursing practice through documentation, enhancing nursing care and participating in quality improvement initiatives. I think I have partially completed this standard through a mixture of classroom and clinical activities. In our leadership class we were tasked with writing a paper to identify a nursing task and apply the process of quality improvement. In clinical practice, we spend a lot of time documenting and charting the nursing care that has been provided. I think actually participating in a quality improvement initiative as a part of the team would help me fully appreciate the standard of quality of practice. Professional Development Goals. Although I have some experience, such as classroom assignments to evaluate a practice for quality improvement, I do not think this will suffice. As previously stated, I think that quality of practice is best achieved by experience in an actual team devoted to quality improvement. Once I become employed I intend to join my employers quality improvement initiatives.

A SELF-ASSESSMENT Communication

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Standard eleven requires that the nurse communicates effectively in a variet y of formats in all areas of practice (ANA, 2010, p.54). The nurse should be capable of communicating with patients and other members of the care team in a variety of ways to pass information, asking questions or voice concerns (ANA, 2010). I am very confident in my ability to communicate, and I think I have proven this ability in a number of settings. In class we must communicate with presentations, class discussions, and papers. In the clinical setting, we have to communicate health information to the patients as well as other members of the interdisciplinary team. I communicate when I give report to oncoming nurses or extended care facility staff, ask my preceptor questions, and update physicians through MMCs paging system. Leadership A nurse who fulfills the twelfth standard of leadership demonstrates leadership in the professional practice settings and the profession (ANA, 2010, p. 55). A leader is responsible, accountable, respectful, helpful, and professional (ANA, 2010). I think I have exhibited some qualities of a leader, in clinical practice as well as among my peers in nursing school. I have been told by some of my fellow classmates that they often look to me for guidance and motivation in the classroom and look forward to being in a group with me because they know that I can provide the group with a leader when necessary. In clinical practice I think I have a lot of room to improve my leadership abilities, but as a nursing student I have shown that I am accountable for the care that I provide to my patients. I also pride myself on the feedback from my clinical instructor that I am always very professional when interacting with my preceptors and my patients.

A SELF-ASSESSMENT Collaboration

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Standard thirteen requires the nurse to collaborate with all of those who may be involved in patient care, including the patient, family and other members of the care team (ANA, 2010). Collaboration allows for improved outcomes, increased communication, and promotes patient autonomy. Collaborating with colleagues creates a positive work environment that promotes cooperation, respect and trust (ANA, 2010, p. 57). Many of our nursing school assignments are group projects, requiring frequent and prolonged collaboration to produce the best result possible. In the clinical setting I frequently collaborate with the nurse aids on the floor. I find that many of the aids are much more familiar with a patient than I am. In one example, an aid and I collaborated with a particularly large patient so that we could safely and comfortably perform a bed bath. Having input from an aid, who has experience with many patients from all walks of life, and the specific patient, allowed us to determine the best course of action. Professional Practice Evaluation The nurse that fulfills standard 14 evaluates her or his own nursing practice in relation to professional practice standards and guidelines, relevant statues, rules and regulations (ANA, 2010, p. 59). This requires the nurse to perform self-evaluations, receive input feedback from colleagues, superiors and patients, and participate in the peer review process (ANA, 2010). Frequent evaluation of professional practice allows the nurse to identify areas of strength as well as areas of weakness, thus promoting professional growth and development. As a nursing student I participate in a lot of evaluation exercises. I am evaluated during simulation lab and clinical practice. I also perform self-evaluations that are submitted to my clinical instructor for review and further evaluation is provided. In fact this very paper is an

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example of self-evaluation in an effort to identify my strengths and weaknesses as I approach the beginning of my nursing career. Resource Utilization The fifteenth standard is resource utilization and requires that the nurse utilizes appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible (ANA, 2010, p.60). The nurse should be able to assess the needs of the patient and determine which resources are needed for successful outcomes. Interestingly, delegation is a part of resource utilization because skilled nursing care is a resource, and delegation allows the nurse to focus his or her skills where truly necessary. I do not believe that I have met this standard yet. I realize that I am often wasteful in the clinical setting; mostly due to lack of knowledge regarding necessary supplies for a particular procedure or mistakes are made. For instance, during a Foley catheter insertion we needed to use another kit because I could not get a return of urine, so we thought I had misplaced the catheter. This patient required three attempts at catheter insertion, each placed by a different nurse, and still did not return any urine. Unfortunately this was near the end of my shift and I never learned why we could not catheterize her even though the catheter was appropriately placed each time. Professional Development Goals. Many experienced nurses have told me that it took 12 years before they felt confident in their nursing abilities. I am hopeful that it will take less time, but realistically, I think it will require a similar amount of time for me to feel comfortable in my knowledge of the proper resources needed for my patients. In an effort to fulfill this standard, I will work closely with my colleagues and my facilitys policy and procedure manual to ensure that protocol is being performed correctly. If I need to perform a procedure that I am unfamiliar or uncomfortable with, I will first consult with a more experienced colleague.

A SELF-ASSESSMENT Environmental Health

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The sixteenth and final standard of professional nursing practice is environmental health. The registered nurse practices in an environmentally safe and healthy manner (ANA, 2010, p. 61). The nurse should have the knowledge and awareness to recognize health risks within the clinical setting that may threaten the patient and/or the health care providers. This includes health risks such as smells, lighting and sounds that could interrupt health outcomes (ANA, 2010). As a nursing student, safety is always greatly emphasized to us in clinical practice. My clinical instructor is a self-proclaimed stickler when it comes to the cleanliness of patient rooms and impresses upon us the importance of clearing clutter, trash and dirty linens from the patient space. I make use of the facilitys receptacles for sharps, medications and bio hazardous materials to ensure that potentially dangerous materials are disposed of safely. Now, when I enter a patients room I scan the environment for potential hazards, such as clutter or twisted IV lines. Code of Ethics for Nurses Provision One The first provision states that, the nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems (ANA, 2001, p.1). I think I fulfill this ethical provision by acting professionally and respectful with all of my patients, regardless of my own beliefs and values that may conflict with my patients. I can recall a patient who was in the hospital due to complications related to her diabetes. This

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particular patient was not taking dietary or physical measures to control her diabetes, and in fact, refused to eat from the hospitals cafeteria and had friends bring her fast food because the physician had placed her on a diabetic diet. After spending the day with my patient and reading through her medical history, I could see that mental health could have been impacting her current diagnosis of diabetes. Whereas some of the staff made comments to each other that my patient brought her illness upon herself, I knew that it was not my place to judge my patient, only to show her compassion and respect. Provision Two The nurses primary commitment is to the patient, whether an individual, family, group, or community (ANA, 2001, p. 1). Provision two requires the nurse to consider the patients interests, even in the face of conflict of interest with the nurse, collaboration and professional boundaries (ANA, 2001). I think that I have upheld this provision in both the clinical setting as well as through classroom assignments. In the hospital I treat individual patients, although I often have to consider the wishes of the family as well, when appropriate. In our community health class a group of my peers and I had to collaborate in an effort to treat an entire county based upon an identified area of need. This assignment taught us that nursing care can be applied to individuals as well as communities. Provision Three Provision three states that the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient (ANA, 2001, p. 1). This provision also covers privacy, confidentiality, and evaluating the practice of yourself as well as others for safety.

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I meet this ethical provision with each and every one of my patients. I protect my patients rights to privacy and confidentiality by complying with the Health Insurance Portability and Accountability Act (HIPAA). I strive to protect the health and safety of my patients through simple, yet powerful actions, such as hand washing and verifying the identification of my patient prior to administration of any medications or procedures. Provision Four The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurses obligation to provide optimum patient care (ANA, 2001, p. 1). While I believe that I hold myself accountable for my nursing actions, I do believe that I still need to work on my delegation skills. As a nursing student I often find it difficult to feel comfortable delegating to others on the floor. I will often ask for assistance with tasks, but rarely ask an aid to complete a task for me. Delegation is a topic that is often covered during class, especially in the style of NCLEX practice questions. I think that I am capable of determining appropriate tasks for delegation, but I think comfort with delegation will come once I have become an RN. Professional Development Goals. While I am still in nursing school I will focus my efforts on developing my knowledge of appropriate delegation. Once I graduate and I begin to work in the clinical setting, I will foster an environment of communication between the aids and myself. I will analyze a situation and determine if my nursing skills are better focused elsewhere and if tasks can be delegated to other personnel. This will be a skill that I need to continually work on, and I hope to show improvement and an increased level of comfort within 6-months of being employed.

A SELF-ASSESSMENT Provision Five

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The fifth provision states the nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth (ANA, 2001), p. 1). This ethical provision requires career-long aspirations for growth. As a nursing student I am learning every day and attempting to become the embodiment of a registered nurse. Once I receive my licensure, I must not only maintain but also cultivate my own personal and professional growth and knowledge. It is important for the safety of my patients that I always remain competent in current nursing practice as it continues to evolve. To maintain my licensure I must seek out education in the form of continuing education units. Provision Six The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action (ANA, 2001, p. 2). Further, nurses are obligated to create, maintain, and contribute to environments that support the growth of virtues and excellences and enable nurses to fulfill their ethical obligations (ANA, 2001, p. 11). As a student who is not yet employed by a healthcare facility, I am not able to participate in collective action, such as a nursing union or shared governance. Once I am employed I hope to become involved in my employers options for collective action. As far as individual actions to improve the health care environment, I hope to lead by example. I believe that one should treat others, both patients and colleagues, with respect and compassion. As I gain more

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experience and become a veteran nurse I hope to create an environment that is welcoming and fosters the growth of student and novice nurses. Professional Development Goals. As previously stated, I intend to join my employers shared governance or union once I become employed. Additionally, I hope to reach out to others to foster an environment of support and open communication. As a novice nurse I will reach out to fellow novice nurses. As I gain experience I will reach out to new nurses so that I can act as a mentor. Provision Seven The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development (ANA, 2001, p. 2). Nurses can become actively involved with policy change by implementing new professional standards or by developing and disseminating new knowledge (ANA, 2001). At this point I do not think that I have had the opportunity to contribute to the advancement of the nursing profession, but I aspire to change that. I intend to pursue an advanced degree in nursing, specifically a degree that will allow me to practice clinically as well as develop and participate in research to progress nursing knowledge. Although that is thinking far ahead into the future, I know that as a registered nurse I can participate in various committees through my place of employment to affect policy change. Professional Development Goals. At this time I do not know which requirements may exist before I join committees at my place of employment, but as soon as I can, I intend to join groups that are capable of making change in the workplace. Additionally, I will use my time to improve my knowledge of new nursing practices. Using my skills to evaluate research I will bring new and promising research to the attention of my managers in an effort to make change.

A SELF-ASSESSMENT Provision Eight

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Provision eight states, the nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs (ANA, 2001, p. 2). On top of a responsibility to individual patients, nurses have an obligation to be aware of the health needs of the community as well as national and international health risks (ANA, 2001). I think that I am a well-informed person and I believe that I will inevitably carry that into my nursing career. As I have previously mentioned, I worked with my classmates to assess and identify a health risk within a Northern Michigan community. Additionally, during my time at my community health clinical rotation my nurse preceptor tasked me with developing an advertisement for the health department. I learned that teen pregnancy is an issue within the mid-Michigan community so I created a flyer to showcase the family planning services offered by the Mid Michigan Health Department. Provision Nine The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy (ANA, 2001, p. 2). I have met this provision, and I intend to continue to be involved with nursing associations throughout my career. I joined Ferris State Universitys Student Nursing Association, and we hold many events and volunteer our time to improve the community, such as holding blood pressure screenings. I have become a student member of the American Nurses Association and I was invited to join Sigma Theta Tau International (STTI), a nursing honor society.

A SELF-ASSESSMENT Conclusion

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Nursing is a constantly evolving field that is primarily concerned with patient safety and quality of care. Standards and ethics, while varied, ultimately serve to guide nurses so that their care with always ensure patient safety and quality of care. As a student nurse it is my job to evaluate myself to determine my level of preparedness for the clinical setting. It is my responsibility to measure my knowledge and skill against the ANAs Standards of Practice and Code of Ethics, so that I am fulfilling my obligation of safety and quality to my future employer and more importantly, my patients.

A SELF-ASSESSMENT References

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American Nurses Association (2001). Code of ethics for nurses with interpretive statements. Retrieved from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/ CodeofEthicsforNurses/Code-of-Ethics.aspx. American Nurses Association (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Nursingbooks.org.