Nursing is a highly dynamic profession, so nurses are called to act as change agents each and every day. One example of a big change on the Burn Unit was the publication of a new fluid resuscitation policy. This new policy gave me an excellent opportunity to work as a change agent on my unit. Essentially, the policy gives instructions for how a nurse or provider should calculate the amount of fluids to be infused over a 24 hour period, considering the size and mechanism of the burn, for adults with a burn 20% TBSA or greater. Then, based on hourly urine outputs, the nurse is given parameters to titrate the crystalloid infusion rate. Additional procedures are also indicated by the policy, such as placing a foley catheter, NG tube, and arterial line.
This new policy certainly applies to the Model of Professional Nursing Practice Regulation. The base of this pyramid model is the American Nurses Association’s Professional Scope and Standards of Practice, as well as their Code of Ethics for Nurses (American Nurses Association [ANA], 2015, p. 35). The new fluid resuscitation policy, as with the old policy, is rooted in foundational nursing skills such as assessing, outcome planning, and excellent communication and collaboration. Burn nurses use those skills every moment of every shift, so the policy did not ask anyone to make changes to any foundational part of their practice. For this part of the pyramid model, being a change agent means to be continually practicing nursing at the highest level of the standards of our profession, and encouraging others to do the same. Participants at this level of the model include the American Nurses Association, patients, and nurses (ANA, 2015, p. 35).
The next level on the pyramid is the Nurse Practice Act of Virginia (ANA, 2015, p. 34). The policy does not violate any laws as set forth by Virginia’s Nurse Practice Act, and so no changes needed to be made at this level (Code of Virginia, 2019). The stakeholders for this level of the Model of Professional Nursing Practice are state legislators and lobbyists, healthcare advocacy groups, political action committees, and nurses (ANA, 2015, p. 34).
The next level up on the Model of Professional Nursing Practice considers the policies and procedures at a particular institution; in this case, VCU Health (ANA, 2015, p. 34). Stakeholders at this level include leaders at VCU Health, the nurse manager and nurse clinician of the Burn Unit, Burn Unit nurses, Burn providers, STICU providers (who also manage care for ICU burn patients in conjunction with the Burn team), and the American Burn Association (who provides verification and accreditation of the Burn unit) (ANA, 2015, p. 34). This is the main level at which Burn nurses were asked to serve as change agents for this policy. Nurses provided specific feedback about problems in executing the orders as set forth by the old fluid resuscitation policy. Based on that feedback, nurse leaders and burn providers collaborated to create a new policy that was easier to interpret and fell in line with new guidance from the American Burn Association. Nurses were then given the opportunity to ask questions and provide feedback about the new fluid resuscitation policy. Then, nurses were asked to implement the new policy when caring for adults with 20% or larger TBSA burns. Acting as a change agent in this case involved not only communicating with nurse leadership and physicians, but also being in charge of educating oneself as well as new staff members. Another important part of being a change agent for this policy is ensuring that new residents and interns rotating through the STICU are aware of the policy change, and being able to explain the necessity of the new policy whenever an unfamiliar provider has questions. This way, severely burned patients receive excellent and safe care, and the lines of communication between the different health professionals stay open and clear.
The peak level of the Model of Professional Nursing Practice is the level of self-determination, at which point nurses exercise their judgment to make decisions (ANA, 2015, p. 35). Nurses are the stakeholders at this level (ANA, 2015, p. 35). For this policy, a nurse must rely on her clinical judgment to titrate fluids based on the parameters set forth in the new policy. Nurses should have critical care training, and Advanced Burn Life Support Training is also a helpful certification. Change agents must also educate themselves about the policy, to ensure there are no gaps in their individual knowledge. An example of this for myself was returning to my Advanced Burn Life Support training literature to reeducate myself about the “4-2-1 rule” referenced in the policy. Essentially, this is a way to calculate a maintenance fluid rate based on patient weight in certain circumstances. I was able to help educate my peers when they had questions as well.
American Nurses Association. (2015). Nursing : Scope and standards of practice: Vol. 3rd edition.
American Nurses Association.
Code of Virginia, Chapter 30, § 54.1-3000 et seq. (2019).