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Reflection and Philosophy Joan A. Kronlein Ferris State University

REFLECTION AND PHILOSOPHY Abstract It is important when transitioning to an advanced practice role, to look at ones practice and philosophy of nursing. Looking at ones practice involves looking at skills, knowledge, and attitudes within the domains of patient-centered care, teamwork and collaboration, evidencebased practice (EBP), quality improvement, safety, and informatics (Quality and Safety in Education for Nurses, 2012), and the American Nurses Associations (2010), Scope and Standards of Practice. This nurse has many skills, much knowledge, and the correct attitude to advance to the next level in nursing. Her philosophy is surrounded by caring and is made up of many different aspects of nursing concepts and theories.

REFLECTION AND PHILOSOPHY Reflection and Philosophy This nurse has been an RN for many years and has worked in diverse settings, ranging from hospital to home care. She obtained her Bachelor of Science in Nursing (BSN) degree in December of 2012. After obtaining this degree, she became frustrated with the role and environment she was working in. Since that time she has continued her education in a graduate program to define her role and expectations for practicing as an experienced BSN/Registered Nurse and person. This paper aims to document the process of transitioning to an advanced

practice role by; looking back at practice to aid in clarifying where she has been, and potentially, where she is going; and documenting her philosophy of nursing using the four metaparadigm concepts and nursing theories (Owens & Singleterry, 2013, p. 13). The following paragraphs outline the knowledge, skills, and attitudes of this nurse displayed throughout her nursing career. This work will coordinate with the competencies outlined by the Quality and Safety Education for Nurses (QSEN, 2012) project and the American Nurses Associations (ANA) Nursing: Scope and Standards of Practice (2010). Information is divided into patient centered care, teamwork and collaboration, evidence-based practice (EBP), quality improvement, safety, and informatics (QSEN, 2012) with the respective knowledge, skills and attitudes (KSAs) within each division. Current Practice This nurses current practice is as a hospital case manager; however, this nurse has been employed in various positions from the school setting to home care. The following is a compilation of KSAs acquired from education and work experience and grouped within each of the QSEN competencies. Patient Centered Care

REFLECTION AND PHILOSOPHY Patient centered care involves recognizing the patient or designee as the source of control and full partnerbased on respect for the patients preferences, values, and needs (QSEN, 2012, p. 1). In this nurses experience, patient centered care means an attitude of humility and true caring; showing and giving patience; seeing with the eyes of empathy; and the ability to perceive and process knowledge about the patient and family. Patient centered care aligns with ANA (2010) standards 1-assessment, 2-diagnosis, 3-outcomes identification, 4 planning, 5-implementation, and 6-evaluation (pp. 32-45). Knowledge. This nurse is accomplished in knowledge of patient centered care utilizing

the nursing process of assessment, diagnosis, outcome identification, planning, implementation, and evaluation (ANA, 2010, p. 9). This includes diversity of individuals regarding culture, preferences, and pain. Skills. This nurse is very skilled at assessing pain and comfort, as well as communication. Communication in all forms is a key skill within this area. This nurse is a great communicator with patients and families. This aligns with ANA (2010) standard 11communication (p. 54). Attitudes. This nurse has the correct attitude which is the willingness to see value and to respect each individual or family member and plan and implement accordingly. This nurse has a caring attitude toward patients, families and coworkers. This aligns with ANA (2010) standard 9EBP and research (p. 51). Teamwork and Collaboration According to QSEN (2012), teamwork and collaboration means function[ing] effectively within nursing and inter-professional teams, fostering open communication, mutual

REFLECTION AND PHILOSOPHY respect, and shared decision-making (p. 4). Teamwork and collaboration align with ANA (2010) standards 7-ethics and 10-quality of practice (pp. 47, 52).

Knowledge, Skills, Attitudes. This nurse understands the value of relationships as key to teamwork and collaboration. This nurse has the ability and desire to work on relationships within the work area. She has proactively counseled team members to work on relationships. She has provided perspective to team members in conflict and has modeled effective conflict resolution. This aligns with ANA (2010) Standard 13-collaboration (p. 57). This nurses strength as well as weakness is communication. This nurse can communicate within a crowd but is much better one on one. This nurse has some anxiety when verbally presenting ideas to large groups, especially peers. This area aligns with ANA (2010) Standard 8education (p. 49). Evidence-based Practice The QSEN (2012) definition of evidence-based practice (EBP) is to integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal care (p. 5). The QSEN competency of EBP directly aligns with ANA (2010) Standard9-evidence-based practice and research (p.51). Knowledge, skills, and attitudes. This nurse has used evidence throughout her career. The type of evidence has changed over time. As a new nurse, the evidence that was used was in the form of hands-on training and verbal instruction from a preceptor or teacher (because EBP was not a common concept in the early 1980s). This nurse has since used journals and medical libraries prior to having online materials. Now, this nurse utilizes the online databases through the Ferris State University library web site for peer reviewed articles about a myriad of questions about best practices. Over time, this nurse has developed a need to understand best practice

REFLECTION AND PHILOSOPHY versus routine (QSEN, 2012) when others cannot explain why they are doing things a certain way. She has cultivated an inquiring mind while keeping the patients values and needs as the precursors to best practices. Quality Improvement Quality improvement is using data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety

of health care systems (QSEN, 2012, p. 6). Quality improvement participation is mandatory for the RN, according to ANA (2010) Standard 10-quality of practice (p.52). Knowledge. This nurse has gained knowledge from school based assignments (ANA, 2010, standards 12-leadership and 8-education, pp. 49, 55), in particular, caring. Research has shown that caring relationships between patients and nurses give better patient outcomes (Ervin, 2006). The perception of feeling cared for is what equates to quality nursing care (ANA, 2010). This nurse has made it her mission to give quality customer service and truly care for patients and families. Skills. This nurse has acquired skills for quality improvement from her bachelor degree program. She has used flow charts, root cause analysis and developed a project about implementing a change. She used evidence to generate some interest in the project which was then implemented in her place of employment. Attitude. This nurse has an inherent ability to see the impact of relationships within a team. She has a caring attitude toward patients and coworkers that shows appreciation for their contributions to the work environment by telling them when they do a good job. Safety

REFLECTION AND PHILOSOPHY As defined by QSEN (2012), safety minimizes risk of harm to patients and providers

through both system effectiveness and individual performance (p. 7). Safety is being mindful of risks to all people within processes and practices. Knowledge. This nurse has practiced safely since nursing school. The difficulty has been in the type of leadership she has been accountable to. Leadership has not fostered open communication about safety and errors but has been punitive and not confidential when discussing errors. Errors have been viewed as individual problems, not system problems. This nurse does not discount the part played by individuals but errors were not used as learning opportunities. This punitive environment fostered hiding of mistakes. This aligns with ANA (2010) Standard 16-environmental health (p.61). Skills. This nurse brought to the attention of leadership that relationships were failing because the environment was punitive. This nurse had strategies for improving the environment with the leadership by suggesting that complaints needed to be taken up the chain of command, not with peers or followers; and that relationships were of the utmost importance when hiring new nurses. Nonverbal communication suggested the message was not heard or appreciated. The above relates to ANA (2010) Standard 10-quality of practice (p. 52). Attitude. This nurse values others and realizes mistakes happen for a multitude of reasons. She also enjoys helping to make the work environment better. Informatics Informatics is use[ing] information and technology to communicate, manage knowledge, mitigate error, and support decision making (QSEN, 2012, p. 9). Knowledge. In this nurses education, she wrote on the evidence and benefits of using an electronic medical record (EMR). The director at the time reviewed the information and started

REFLECTION AND PHILOSOPHY on an implementation plan. This nurse researched different EMRs for her place of employment

and prepared statements about the potential benefits to patients as well as the work environment. This relates to ANA (2010) Standard 15-resource utilization (p. 60). Skills. This nurse is proficient in the EMR used within her work environment. This nurse teaches others, in particular, her clinical coordinator, how to use the technology when the need arises. This aligns with ANA (2010) Standard 13-collaboration (p. 57). This nurse values technology and the potential for reducing risk (old records are easily obtained and medications are automatically checked for interactions). She enjoys learning new technology and helping others find value in technology as well. Reflection on Knowledge, Skills, and Attitudes This nurse has been on a journey to find value and meaning in her work related to her intrinsic personality and as a BSN. This nurse realizes that she is a quiet and thoughtful person, not the norm for leadership. This nurse has taken a proactive stand. A quiet and thoughtful person can be an effective leader and, as such, she has resigned from the stifling and punitive environment in which she has been employed. She realizes that she needs more education, especially in communication and will seek out ways to practice in groups. The above information aligns with ANA (2010) standard 14-professional practice evaluation; the registered nurse evaluates her or his own nursing practice in relation to professional practice guidelines (p. 59). This nurse will be an awesome leader because she has the ability to know and understand what others need in relationships within the work environment. A Bias of Caring As important as understanding knowledge, skills, and attitudes of ones work is, so too, is understanding ones philosophy. This nurses philosophy of nursing is underpinned by caring.

REFLECTION AND PHILOSOPHY Underpinning is to strengthen or support (something) from below (Merriam-Webster, 2013, para. 1).The word, bias, implies a negative problem. This nurse prefers the term, positive bias instead of underpin, which implies from below. This term is important within the

philosophy section of this paper as most of what has been thought of as nursing theory in caring, has been to my particular practice, a positive bias. My bias is having a caring attitude towards all people; however, being caring and having a caring attitude is not specific to nursing (Thorne et al. 1998), nor is it everything that nursing is. This nurse liked the caring theory of Jean Watson because it aligned with her self-perception. Caring is an important aspect of being an excellent nurse. It can be taught in a nursing program but is not where this nurse initially learned this behavior or attitude. I learned a caring attitude from parents, religion, family members, and from an innate sense of right and wrong. This nurse already brought caring to her nursing practice; it was not instilled from a nursing education program. It was enhanced within her education as an important aspect of being a nurse. Caring is part of who this nurse is and the environment that she creates around each person she is in contact with. It is a foundation that surrounds her practice. Caring is the positive bias that surrounds the following personal nursing philosophy which includes explanations of person/patient, health, environment, and nursing (Thorne et al., 1998). Philosophy A philosophy of nursing includes a conceptual clarification and assessment of arguments (Edwards. 1997, p. 1092); consideration of general existence and knowledge questions and the relevance to nursing (Edwards. 1997, p. 1092); and the development of a framework for discussing philosophical questions (Edwards, 1092). In other words, a philosophy clarifies questions of what constitutes a nurse, a patient, health and the environment, and the

REFLECTION AND PHILOSOPHY framework that surrounds how these terms are defined which helps answer questions about interactions between and about them. This nurses philosophy is not complete and will continually evolve based on meaningful information received and given via her education program and nursing experiences. There are different pieces of many concepts that would constitute her philosophy, at this time. One area that has been constant is the positive bias of caring, as explained above. The following is a description of what constitutes a patient/person, health, the environment, and nursing by this nurse and helps define her philosophy of nursing. Patient/Person


A patient or person (or group) is a complex adaptive open system and the one the nurse is interacting with at any given time specific to when the nurse is acting within her role as a nurse (Clancy et al., 2008; Tourville & Ingalls, 2003). The person can learn and adapt to change over time (Clancy et al., 2008). The person or patient is adaptive because to gain health they must change or respond to a treatment regimen the nurse assists them with. This patient/person definition fits with how this nurse already views patients and their potential. Health Health is the patients defined (Tourville & Ingalls, 2003) optimal level of well-being, wherein the nurse can help the patient see potential for optimal well-being that perhaps the patient does not see. The nurse assists with adaptation to a new (patient defined) optimal level of well-being when life stressors of mind, body, or spirit (Tourville & Ingalls, 2003) interact with the patient. This concept of patient defined health is not new. This nurse was already taught, through continuing education, that what is health for one person is not health for another. The above citations reiterated this nurses concept of health. Environment

REFLECTION AND PHILOSOPHY This nurse believes that the environment is an open system that interacts, changes or adapts based on the person/environment exchange (Reed, 1991). The open system of environment can be ideas surrounding situations or attitudes (peace, calm, love, hate), history and what is or was in the world, the living organisms that surround people as well as the planet earth, families, friends, and work, to name a few (Reed, 1991). A new concept this nurse has learned is she is part of the patients environment (Reed, 1991) and, as such, can change and adapt to help the patient change or adapt. Nursing


The nurse is part of the environment and is an open complex adaptive system (Tourville & Ingalls, 2003; Clancy et al., 1978). Nursing is defined as the use of patterns of knowing that allow the nurse to interact with and assist with adaptation when the person or patients defined optimal level of well-being is not obtained (Carper, 1978; Clancy et al., 1978; Tourville & Ingalls, 2003). The patterns of knowing really helped this nurse understand herself as a human being and as a nurse; and justified her use of this type of knowledge in her nursing practice. Conclusion When transitioning to an advanced practice role, it is important to look back at ones knowledge, skills, and attitudes, as well as, understanding ones own nursing philosophy. It is important because it creates unique nursing knowledge, strengthens ones practice, and may be useful to the nursing profession in the future (Owens & Singleterry, 2013). This nurse has much knowledge, skills and the right attitude which is surrounded by caring: caring for the patient; caring to achieve health; caring within the environment; and caring in the practice of nursing.


REFLECTION AND PHILOSOPHY American Nurses Association. (2010). Nursing scope and standards of practice. (2nd ed) Silver Spring, MD: Author.


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