Core Competencies in Training

One of the greatest challenges of nursing is providing quality and empathetic care that meets the needs of the patient while preserving the emotional status of the professional. Tending to burn unit patients on a regular basis can drain the emotional reserves of the nurse and cause compassion fatigue. This actually works at cross-purposes to all of the people under the nurse’s care. It is a natural human response; and almost a prerequisite for those entering the field; to want to extend oneself benevolently in the face of another’s suffering. However, competent nurses recognize that their greatest asset is in providing the medical support necessary to alleviate physical suffering to the extent possible. 

In light of this, a set of core competencies have been developed as a framework for interacting with burn unit patients and their loved ones. As nursing students become familiar with their responsibilities in authentic medical settings the order of implementation regarding these competencies is fairly evident. The practitioner must tend to pain management first; and then address other physical needs. Too, the nurse is responsible for helping a patient and his or her family to cope with the reality of the ailment and their own sense of bereavement. Finally, the nurse acts in concert with an entire team of professionals who each bring separate skills to the care of the patient. 

In this essay we will provide several opportunities for the student nurse to gain expertise in the specific field of burn unit nursing. Included will be a set of four competencies tailored to national nursing standards with five accompanying objectives utilizing the GEM model for each new concept that is introduced. Student nurses should be forewarned that burn unit nursing is especially grueling and the ability to hold one’s emotions in check is imperative to competent field work. The GEM nursing model is invaluable in providing authentic learning experiences; and helping students gain a grasp of the nuances of the profession as well. According to one research study a first step in internalizing nursing responsibilities is in understanding the very difference between guidelines and protocols – a basic conceptualization. “The terms “guidelines” and “protocols” are not synonymous. Guidelines typically provide direction for clinicians asking questions such as, “What should I do for a patient with this type of condition,” while protocols tend to answer questions such as, “What should I do for this specific patient with these specific health issues in this specific setting?” (Koch, Woodcock, Harris 2010). This model will be especially helpful in completing the two clinical activities that accompany this assignment. In each case the student nurse will be asked to differentiate between guidelines and protocols while completing the exercise.

Addressing the patient’s pain is the first competency to be considered (Board of Nursing, n.d.); and research across the breadth of academic journals confirms it is of utmost importance in the delivery of nursing care. However, this singular responsibility is often complicated by the degree and extent of the burn. “Burns are considered to be among the most painful types of trauma” (Kohler 2003). Studies show that “strong opioids are the mainstay of any pain management regimen in burns patients; of which morphine is accepted as the ‘gold standard’” (Byers 2001). Unfortunately, opioids lead to respiratory depression; which underscores the value of best practice applications regarding burn unit patient pain management. 

Moreover, improper pain management comes with its own set of concerns as noted in the Pain Management Nursing Role Core Competency Guide for Nurses. Among the many problems associated with improper pain management is substance abuse and depression - which may hasten a patient’s death; alleviating pain may mask other symptoms; realizing that pain can only be assessed through patient behavior; pain is subjective and understanding the continuum of pain along the age spectrum. This brief explanation of the complexities of pain reaffirms the importance of having the competency to address it properly on behalf of the nursing staff and its choice as a topic for study. 

Generally speaking, National Standards for Nursing relate that a nurse ‘must provide relief from pain and other symptoms through administering medication, under the guidance of a medical doctor’. (Objective C) This requires a nurse to be knowledgeable about pain. 

1. The nurse utilizes the nursing process in the management of pain (Board of Nursing, 2004, p. 3).

a) The nurse utilizes a developmentally appropriate, standardized pain assessment tool which includes: a pain measurement tool that has demonstrated reliability and validity and patient participation which is essential in the assessment process. The assessment process and results must be charted.

b) For those incapable of self-reporting (often the case with burn victims) standardized pain assessment tools should include behavioral observations with or without physiological measures. Suggested physiological measures may include (but not be limited to) tachycardia, hypertension, diaphoresis and pallor. The assessment process and results must be charted.

c) The nurse will utilize the information from the pain assessment to decide a course of clinical action regarding the type and amount of pain medication to administer. It is important for the nurse to realize that this information is subject to change based on their ongoing pain assessments. (Objective D)

d) The nurse will be responsible for administering the proper dosage of pain medication at the time intervals determined by the pain assessment. (Objective D)

e) When possible, the nurse must keep the patient apprised of their condition and the effects of the pain medication.

The second competency requires the nurse to meet the standards for professional practice by providing palliative care that integrates the multiple therapeutic approaches in use. (Objective C) 

2.  The nurse must manage the ongoing effects of burn treatments.

a) The nurse must assess the level of patient distress through behavioral observations.

b) The nurse must provide education about the treatments.

c) The nurse must assess the quality of life for the patient as a cost benefit analysis.

d) The nurse must discuss viable treatment options with the treatment team for the client before treatment is provided as demonstrated by team staffing notes. (Objective d)

e) The nurse must provide support to the patient’s family throughout treatment.

Competency three involves tending to the patient’s mental health; addressed by the national nursing standard of accurately managing client care including mental health challenges by providing a coping support system. The nurse will need to be able to provide support for the burn patient’s mental health during the treatment process. As with nearly every task in nursing, it is an ongoing requirement and part of the total nursing process. The standard as it is stated – the professional nurse must offer a support system to assist the patient adjust and cope with the illness - belies the complexity of the competency. In truth, “burn patients often face months of painful treatment that may include skin grafts, physical rehabilitation and adjustment to a new appearance that can be unsettling if not devastating to the individual” (Greenfield 2010).  (Objective C)

3. The nurse must assess and refer the client to services to address the feelings. 

a) The nurse must monitor the mood and anxiety levels through standardized assessments and patients’ self-report conducted on a daily basis and included in the patients’ chart.

b) The nurse must refer the patient to social work or a mental health agency so the client can process the diagnosis on an as needed basis as measured by the nurse case notes.

c) The nurse must discuss the mental health and medical needs of the patient before the referral. (Objective D)

d) The nurse must develop a safety plan with the family in case the patient becomes suicidal and include notes in patient chart.   

e) The nurse must provide mental health support group information to the family (as well) so that they can adjust to the mental illness. This is recorded in nursing notes. 

Finally, in cases where the patient does not survive the nurse must be competent in the Nursing Standard expectations that state the professional is able to interact appropriately with family and staff and be able to offer the grieving family a level of support in their bereavement. (Objective C).

4. The nurse must refer patients to community resources.

a) The nurse must prepare the patient through providing information and resources

to the client and family.

b) The nurse must assist the family and patient attend support groups which other families going through a similar situation.

c) The nurse must assist the family in directing them to proper funeral organizations. 

d) The nurse must always provide quality of life care for critical patients not likely to survive their injuries.

e) The nurse must follow up with family at least two weeks after the patient has passed away to monitor how they are coping with the loss as recorded by nurses’ notes.

Students will be required to complete a series of role-playing activities as a condition of passing this module. First, students will be asked to assess the mental health of several burn patients in varying stages of the healing process and with different degrees of burns. A burn victim’s mental health may be much more precarious than in other conditions; making this practice invaluable to the learner. In each case the nursing student must provide an assessment and course of action for the patient as a part of the overall plan of treatment. (Objective D2).

In the delivery of the authentic clinical activity the student nurse will be asked to assess the level of pain for a conscious and unconscious burn victim and then prescribe a dosage and treatment plan. Students should chart their pain assessment. In both cases; the role-playing patient will have high levels of pain that will require the practicing student nurse to draw on a variety of techniques to complete the assessment. This exercise can be repeated over the course of several days – with the health of the role-player either improving or deteriorating to provide the student nurse with an opportunity to develop capabilities in the area of long-term diagnosis. (Objective E)

(Grading scale omitted for preview. Available via download)

Students will be additionally advised that if they perform below the level of a B, they should consider retaking the module. It is expected that as the student nurse concludes this course of study, he or she will have gained a level of competency in the specialty area of burn nursing. No matter what area of nursing one chooses to pursue; it is a rewarding field. 

However, there is no substitute for experience and expertise; both of which can acquired with nursing practice such as in the aforementioned exercises. The human body is a wondrous machine; but when it malfunctions (as it does so often) and corrective measures are required; nurses play a pivotal role in supporting patients through the rehabilitation process. It is advised that the nursing student become familiar with the entire list of standards and objectives that must be internalized to enjoy success in the workplace. 

References

Byers, B. (2001). Burn Patients' Pain and Anxiety Experiences. Journal of Burn Care & Rehabilitation: 22(2); pp 144-149.

Greenfield, E. (2010). The pivotal role of nursing personnel in burn care. Indian J Plast Surg.43(Suppl): S94–S100.

Koch, K.; Woodcock, M.; Harris, M. (2010). Representation of Clinical Nursing Protocols Using GEM II & GEM Cutter.AMIA Annu Symp Proc. p. 397–401.

Kohler, E. (2003). Comparison of Patient Satisfaction and Self-Reports of Pain in Adult Burn-Injured Patients Journal of Burn Care & Rehabilitation: 24(1) ;pp 1-8

Wendell, R. (2004). Improving pain management for patients in a hospital burns unit. Nursing Times.net. 100(11): p. 38.