Running head: TRANSITION PAPER A & B
Professional Transition Paper A & B
Alyssa L. Peterson
Ferris States University
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TRANSITION PAPER A & B
Abstract
Nursing is a discipline unique from any other. My own practice has been developed through multifaceted sources. In the following sections I will explore the characteristics of my nursing practice, my definitions of the four metaparadigm nursing concepts, and nursing
2 theories/theorists that have helped cultivate my interaction with patients. In addition to these factors, I will also discuss the transition from novice nurse to advanced practice nursing.

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Professional Transition Paper A
One of the many benefits of being a registered nurse is the countless job opportunities.
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One degree can yield multiple careers within the profession, and advancing that degree opens the door to numerous additional prospects. Although there are several types of nursing, there are standards of practice that are applicable for all registered nurses (American Nurses Association
[ANA], 2010, p. 2).
In the short time that I have practiced as a registered nurse I have had experience with a few of these different types of nursing. After graduating with an Associate Degree in Nursing from Ferris State University in 2008, I was hired as a casual employee at North Ottawa
Community Hospital (NOCH). While completing a Baccalaureate Degree in Nursing, I worked as a float nurse on the Medical Surgical Floor and in the Obstetrics and Intensive Care Units. In
2009 I graduated from the RN to BSN program at Ferris. At that time I had the opportunity to take a full time position on the Medical Surgical Floor at NOCH. The experience I gained while working on the Medical Surgical Floor was incredibly valuable and necessary for my nursing career. The purpose of this paper is to identify the knowledge, skills, and attitude required for my current practice and explore what it takes to transition to an advanced practice nurse.
Current Practice
As explained by Benner (1982) there are stages that one must transition through to move from novice nurse to expert. The five stages include novice, advanced beginner, competent, proficient, and expert (Benner, 1982). I started on the Medical Surgical floor at NOCH as a novice nurse. After a period of time, I met Benner’s stage of competency “characterized by a feeling of mastery and the ability to cope with and manage the many contingencies of clinical nursing” (1982, p. 405). After reaching this stage I was ready for a challenge. I decided that the

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Emergency Department is where I would gain the most diverse practical experience. After working in the Emergency Department for approximately two years I have advanced to working
4 as charge nurse and also acting as preceptor for new employees. The amount of experience I have gained while working in Emergency Department, Medical Surgical Floor, Intensive Care and Obstetric Units has been remarkable. In the following sections I will discuss the knowledge, skills, and attitude needed for my current practice.
Knowledge
Nursing knowledge is expanded from a collaboration of multiple different sources. These sources include scientific, personal experience and understandings (Moule & Goodman, 2009).
“Knowledge encompasses thinking, understanding of science and humanities, professional standards of practice, and insights gained from context, practical experiences, personal capabilities, and leadership performance” (ANA, 2010, p. 12). Much of the supplementary nursing knowledge required for working in the Emergency Department is provided in the form of on the job training. This can include classes, training, seminars, simulations, and continuing education credits. The certifications required by the employer to work in the Emergency
Department are basic cardiac life support, advanced cardiac life support and pediatric advanced life support. Additional training required by the Emergency Department management at NOCH is telemetry and twelve lead electrocardiograph classes. A nurse must be proficient with reading telemetry strips and electrocardiographs while working in this department.
An in depth knowledge of the electronic medical record and electronic charting system is also a requirement for many fields of nursing. From the EMR one can obtain information about previous visits to the Emergency Department, past medical and surgical history, and prescribed medications through internet connection to local pharmacies. Access to previous medical records

TRANSITION PAPER A & B can help to formulate a complete assessment of the patient ultimately leading to the desired outcome. Background knowledge, previous experience, and additional training are the foundations for the skills required to care for a patient.
Skills
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Integrating nursing knowledge into actual nursing practice can be done using the ANA’s standards of practice. The ANA states that “The Standards of Professional Nursing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently” (2010, p. 2). The website for NOCH provides a description of medical services available in the emergency department.
Currently, duties are outlined to include “emergency assessment, triage, evaluation, stabilization, treatment or transfer services are provided for all emergency conditions and diagnoses” (NOCH, 2013, para 1). The first step in patient care in the Emergency Department is triage. Triage falls under the first ANA standard, Assessment. Information that is appropriate to the current condition is obtained during the initial assessment of a patient (ANA, 2010). The triage of a patient includes current symptoms and duration, vital signs, past medical and surgical history, family medical history, medications, previous treatment, and any other data that is pertinent to the chief complaint. The immediate treatment or interventions provided for the patient depend on the chief complaint and current symptoms. For example, if the stated chief complaint is chest pain the registered nurse would obtain an immediate electrocardiograph, place the patient on the cardiac monitor, and obtain a set of current vital signs. The RN would also start an intravenous line, draw blood for the laboratory, and assess for the need of supplementary oxygen. The pertinent data and results from the initial protocol are presented to the physician. After completing an assessment of a

TRANSITION PAPER A & B 6 patient, the registered nurse can use the results and formulate an appropriate diagnosis. Diagnosis is the second standard of practice (ANA, 2010).
Once the assessment and diagnosis are completed the nurse along with the collaborative health care team can then articulate an expected outcome and the planning and implementation it takes to get there (ANA, 2010). The ANA’s (2010) standard of outcome must be formulated specifically for the patient and the patient’s family. The outcome must also consider the cultural aspects, risks verses benefits, and a timeline for the projected outcome. While implementing the desired plan, the nurse must consider the latest research and evidence based practice that best match the patient and his/her diagnosis. According to the ANA, the nurse must also consider the impact of the cost for the desired treatment and interventions. After implementing a plan for the chosen outcome there must be a way to evaluate whether the outcome was reached. Evaluation is another important standard of practice presented by the ANA (2010). However, since emergency medicine does not involve continuing care of a patient, evaluation of a desired outcome requires follow up with the patient’s primary physician, specialists, or inpatient physician if admitted into the hospital.
In the Emergency Department the registered nurse works together with the other health care providers to work through the nursing process. It is a collaborative effort between the registered nurse, physician, physician’s assistant, respiratory therapist, medical imaging technicians, phlebotomist, laboratory, and/or many more. Through laboratory results, medical imaging, physical and psychological assessments, and patient status one can develop a diagnosis and plan for implementing treatment and interventions to arrive to an expected outcome.
Collaboration is another standard identified by the ANA (2010). The ANA states that the registered nurse “collaborates in creating a documented plan, focused on outcomes and decisions

TRANSITION PAPER A & B related to care and delivery of services, that indicates communications with patients, families,
7 and others” the registered nurse also “partners with others to effect change and generate positive outcomes through knowledge of the patient or situation” (2010, p.136).
Attitude
Since the entire nursing process cannot be completed by one individual nurse, the RN must be proficient in working as a team. As mentioned before, caring for a patient is a collaborative effort. Each member of the health care team plays a part in the development of the nursing process. Without one piece the entire process would be unsuccessful. Through the collaborative efforts the RN has the key elements in the assessment to diagnosis, and then develops a plan that is implemented, and finally arrives to the expected outcome.
An Emergency Department RN works side by side with the physician and other nurses. One must always keep an open mind to learning new things.
Another standard of the ANA is collegiality. “The registered nurse interacts with and contributes to the professional development of peers and colleagues” the RN also “maintains compassionate and caring relationships with peers and colleagues” (ANA, 2010, p.135). The development of healthy relationships between coworkers is as important as the relationship built between RN and patient. Not only should the nurse work as a team player, the RN should also be a team builder. An RN shows leadership through providing a positive work environment, valuing the success of other nurses, showing enthusiasm for superior patient care, accepting mistakes when they happen, and finding ways to improve nursing care (ANA, 2010).
Leadership is another standard identified by the ANA (2010, p. 142). At NOCH’s
Emergency Department there is a designated charge nurse. The role of the charge nurse closely follows the guidelines of the standard leadership. The charge nurse must facilitate the flow of the

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Emergency Department, encourage constant communication between the members of the health
8 care team, and monitor for updates in patient statuses. It is also the job of the charge nurse to keep the morale of the department upbeat and monitor the satisfaction of the patients and families visiting the department. The ANA (2010) states that the RN “directs the coordination of care across settings and among caregivers, including oversight of licensed and unlicensed personnel in any assigned or delegated tasks” (p.142). Delegation is another important responsibility of the charge nurse in the Emergency Department setting. Many nurses in the
Emergency Department at NOCH feel as though working as charge nurse is both an honor and a curse.
Reflection
Working as an RN, with a baccalaureate degree, in the clinical setting has been both informational and rewarding. The experience I have gained over the past five years is invaluable and something I will continue to utilize regardless of my level of practice. I have learned that while the nursing process is always the same, each patient is unique in their own way. There are many great things about bedside nursing, but perhaps the best is knowing that you have touched someone’s life in a positive way. Although my practice thus far has been rewarding, I have a passion for education and desire a greater knowledge base and nursing practice. According to
Tourville and Ingalls (2003) “nurses need to develop their practice of nursing as it best applies to the client or person, the environment, the client’s culture, and the nurse’s level of understanding and philosophy” (p. 30). By eventually becoming an advanced practice nurse, I hope to expand my experience and enhance my nursing career while developing the current knowledge, skills, and attitude I currently possess. Using nursing theory and philosophy development is one way to enhance a nursing practice.

TRANSITION PAPER A & B
Philosophy
In addition to the knowledge, skills, and attitudes needed for practicing nursing it is also
9 important to integrate philosophy into the discipline. “A philosophy, by definition, is a set of basic beliefs, values, and attitudes held by an individual or a group or a way of thinking about the world (nursing) and asking the who, what, why, where, when, and how questions” (Alpers et al.,
2013, para. 4). Nursing philosophy has developed significantly over the last one hundred years.
Long before the introduction of evidence-based practice, Florence Nightingale proposed that research and theory development should be an important part of the nursing profession (Alpers et al., 2013). Nightingale believed nursing is a science based on statistics, facts, and research.
However, she also believed that nursing is an art and each nurse should develop his/her own unique philosophy that is cultivated using established nursing theories and models (Alpers et al.,
2013). An important aspect of nursing philosophies and theories are the four metaparadigms concepts. These metaparadigms include person, environment, health, and nursing (Tourville and
Ingalls, 2003).
My own practice has been developed from my previous experiences, in addition to, established theories and evidence-based practice. One theory that relates well to my nursing practice is the Theory of Interpersonal Relations developed by Hildegard Peplau (Peplau, 1997).
Peplau (1997) states “the nurse-patient relationship is an interpersonal field, the data of which can be examined within the dyad as a basis for greater self-understanding and learning” (p. 162).
In the following sections I will discuss my personal philosophy and definitions of the four nursing metaparadigms.

TRANSITION PAPER A & B
Person
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The first metaparadigm concept of nursing is person. In my own practice I define person as the individual seeking care from the health care provider. Including the extension of the patient such as family members, significant others, and caregivers. Along these same lines,
Tourville and Ingalls (2003) define person as “the individual with whom the nurse is interacting in a therapeutic manner” (p. 22). According to Tourville and Ingalls (2003) the person may also include a group of people, such as a family or community.
Peplau’s Theory of Interpersonal Relations is implemented well in the Emergency
Department setting. Tourville and Ingalls (2003) state that “Peplau describes the patient as one who needs and seeks the service of a nurse to help solve any health problems” (p. 24). Senn
(2013) identifies the importance of affective communication between the patient and the nurse in the Emergency Department. Because the interaction may be brief, the nurse must identify the patient and his/her needs efficiently. At times the patients arriving in the Emergency Department may not be verbal or responsive. Senn (2013) identifies these situations as an important time to include the family, friends, or caregiver of the patient in the metaparadigm concept of person.
Senn (2013) states “it is essential for the emergency nurse to communicate proactively with the patients and their families utilizing empathy, assertiveness, and active listening” (p. 33). Positive communication with the patient or extension of the patient promotes effective, efficient patient care in the Emergency Department.
Health
The third metaparadigm concept of nursing is health. In my own practice I define health as no longer simply the absence of illness in a patient but the state at which one is living to the highest quality most appropriate for the individual. One theory that has helped establish my

TRANSITION PAPER A & B 11 definition of health is the Developmental Health Model cultivated by Allen (Ford-Gilboe, 1994).
Allen’s theory encompasses the idea that health is not only the absence of illness or disease but the desired amount of health. Health is affected by development and coping (Ford-Gilboe, 1994).
“An optimum state is defined by a high degree of health and no illness. Less satisfactory states exist when either: (a) there is a high degree of health, and illness is present, or (b) there is a low degree of health, and illness is absent” (Ford-Gilboe, 1996, p 116). According to Allen health and illness are two different concepts. However, each of these things affects the other (Ford-
Gilboe, 1996). In any field of clinical care each individual’s standard of health is not equal.
What may be a quality life to one may not be to another. This is why I believe that health is the state at which one is living to the highest quality most appropriate for the individual.
Much like the concept of person, health is also affected by the extension of the patient.
Allen believes that health is highly affected by the family’s learned coping skills (Ford-Gilboe,
1996). What is viewed as the highest quality of health is also affected by the family. This is a learned concept and is different for each patient.
Environment
The second metaparadigm concept of nursing is environment. In my own practice I define environment as a two part concept including the area where the care is provided and the patient’s home setting. Tourville and Ingalls (2003) state “the environment is not exclusive to the hospital setting. It may be freestanding clinics, nursing homes, schools, corporations, or homes” (p. 22). The environment can be considered any place that the patient seeks therapeutic care (Tourville & Ingalls, 2003). This would include the Emergency Department in my current nursing practice. According to Allen an environment is any place that education of a patient takes place (Ford-Gilboe, 1994).

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I have found that one essential aspect of the patient’s environment is the home setting.
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Similar to the previous metaparadigm concepts the family is a significant part of the patient.
When caring for a patient in the Emergency Department one must take into consideration where the patient is coming from. What social or cultural standard have they developed throughout their lives? According to Allen supportive environments “include a valuing of the ordinary events of family life as legitimate opportunities for growth, availability of knowledge and resources…and the provision of opportunities for families to view health as an integral part of family life” (p. 116). A patient’s home environment has a significant impact on his/her idea of what health is and also his/her perception of health care.
Nursing
The fourth and final metaparadigm concept is nursing. In my own practice I define nursing as the following. Nursing is providing quality care to the patient while developing a relationship that facilitates optimum patient care and education. Tourville and Ingalls (2003) state that “especially in these times, the nurse is not only responsible for the physical care of the patient, but also has an intricate relationship with him or her” (p. 22).
The three phases of the nurse to patient relationship defined by Peplau are similar to the
AIDET tool used by the nurses at NOCH. Peplau acknowledges that first is the orientation phase.
Peplau (1997) states “the orientation phase is the time to begin to know the patient as a person, as well as to obtain information on the health condition” (p. 164). Using the AIDET tool the letters A, I, and D represent acknowledge, introduce, and duration (Scott, 2012). This falls under
Peplau’s first phase, the orientation phase. It is important for the health care provider to smile and make eye contact while introducing oneself to the patient. Scott states that “this warm and accepting acknowledgement puts the patient at ease” (2012, p 31). An introduction of who you

TRANSITION PAPER A & B are and what your job title is decreases the anxiety of the patient (Scott, 2012). It is also important to explain to the patient how long it will take to complete the task at hand. This falls
13 under the duration category of the AIDET tool (Scott, 2012). Peplau’s first phase and the first three steps of the AIDET tool fall into the triage stage of caring for a patient in the Emergency
Department.
Peplau’s second stage is the working phase (Peplau, 1997). Tourville and Ingalls (2003) identify that during Peplau’s third phase “the nurse provides physical care, educates the patient about his/her illness and what the patient can do to help promote his/her health, and provides support and counseling for the patient” (p. 24). According to Peplau (1997) it is the nurse’s responsibility to education the patient using whatever method is most appropriate for the individual. It is during this phase that I use the E in the AIDET tool representing explanation or education (Scott, 2012). Scott (2012) states that “the primary goal of the explain stage is to enlist the patient in the level of care. All patients have the right to know what is going to happen to them” (p. 31). I have found that by actively involving the patient in stage of care produces the most successful outcomes.
Peplau’s third phase is the termination phase. This phase includes closure of the relationship (Tourville & Ingalls, 2003). It is during this phase that “the nurse and patient review the discharge plan…medications, and follow-up appointments” (Senn, 2013, p. 33). In the
Emergency Department is it also in this phase that the nurse reviews the signs and symptoms to watch for and when to seek further care (Senn, 2013). The T in the AIDET tool represents thank you. During this stage of interaction with the patient the nurse thanks him/her, asks if there are any other questions, and says a goodbye (Scott, 2012).

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The relationship between the nurse and the patient in the Emergency Department is unique from any other form of nursing. Senn (2013) states that “in the emergency department
14 setting, the nurse uses the phases of the nurse-patient relationship in briefer periods since the average emergency room visit is usually less than four hours” (p. 33). The amount of time spent with the patient is most often times brief and it is important to know how to facilitate a healthy relationship early on in the visit.
Nursing Theory
Nursing theory has become recognized as a necessary part of the nursing profession
(Ford-Gilboe, 1994). Long gone are the days where nursing was merely a nurse following a physician’s order. “Nightingale believed that nurses should be well-educated and practice independently” (Tourville & Ingalls, 2003, p. 22). The development of both the science and art behind nursing has enhanced the nursing profession over the past one hundred years and continues to do so. Ayres (2013) states
My hope is that nurse scholars (and nurse educators) will create a discipline that is informed equally by science and the humanities, a discipline whose moral and intellectual center is practice. I would like to see nurse scholars as collaborators not only with medicine and pharmacy but also with literature and history, geography and philosophy.
(p.327)
Nursing theorists like Peplau and Allen have shaped the way that all nurses practice in this unique profession. They show us that although science is an essential aspect of nursing, theories and philosophies are just as significant. According to Peplau (1997) “nurses need theory and techniques of interviewing and counseling, for it is during these relationships that nurses make observations, ask and respond to questions, and obtain and use vital personal information” (p.

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163). It is evident in these nursing theories and many others that “to care for and to care about
15 the person are two essential components of nursing” (Tourville & Ingalls, 2003, p. 30). The continued development of nursing theory has shaped the nursing profession, especially advance practice nursing, into what it is today.
Conclusion
My own philosophy has been, and will continue to be, developed through multifaceted sources. I believe that high quality patient care is the nurse’s responsibility first and foremost and is extended to the people that shape the patient’s expectations and environment. It is true, science is necessary for the survival of the nursing practice. However, science will not help with the comforting of a patient or their family (Ayres, 2013). I consider the ability to foster an effective and productive relationship with the patient, to be one of the most significant parts of nursing.
The capability to do this in any profession or life in general, is considered an art.
I believe that high quality patient care is derived from nursing research, evidence-based practice, and well cultivated nurse-patient relationships. Nursing research started with Florence
Nightingale in the 1800s and has grown substantially since (ANA, 2010). The ANA (2010) recognizes that “nursing research was able to flourish only as nurses received advanced educational preparation” (p. 15). With continued education comes a forward-thinking and innovative nurse. By furthering my education and experience, I hope to enhance my nursing practice to a level of success that brings even higher quality care to the patient.

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