The Attending Registered Nurse

INSPIRATION | INNOVATION | TRANSFORMATION

THE NORMAN KNIGHT NURSING CENTER FOR CLINICAL & PROFESSIONAL DEVELOPMENT

The Attending
Registered Nurse
R. Gino Chisari, RN, DNP
Director
Norman Knight Nursing Center for Clinical &
Professional Development


The ARN Defined

The Attending RN (ARN)
• Ensures collaboration
• Is a consistent presence throughout and
following the patient’s hospitalization
• Core competencies allow the ARN to serve as a
clinical coordinator, facilitator and mentor in
order to cultivate a safe, efficient and effective
environment of care


Theoretical Basis

Presence through Attunement
• It is what happens when connection is made and
each person experiences the other as present
• It is through attuning that we form relationships
and our experiences becomes aligned
• The capacity to attune to our patients and
families is a prerequisite for therapeutic care
• It’s not a task; it’s an intentional use of self and
the container for the therapeutic practices of
wondering, following and holding
“See me as a Person: Creating Therapeutic Relationships with Patients and Families”, Mary Koloroutis and Michael Trout, 2012


Theoretical Basis

Wondering
A practice of discovery grounded in curiosity and
genuine interest in others
Following
The practice of listening, respecting and acting on what
we learn from our patients and families
Holding
Creating a safe haven for healing in which people feel
accepted and held with dignity and respect
“See me as a Person: Creating Therapeutic Relationships with Patients and Families”, Mary Koloroutis
and Michael Trout, 2012


The ARN Selection Criteria

A staff nurse who has:
• Strong interpersonal relationship skills
• Emotional intelligence
• Resiliency
• A sense of humor
• Credibility with all members of the team
• A sense of joy


The ARN Selection Criteria

A staff nurse who has (continued):
• Clinical expertise
• The ability to be flexible, creative, innovative
• The ability to act calm under pressure
• Passion
• A bit of risk taking behavior
• Commitment to the power of the role


The ARN Competencies

Core Competencies:
• Communication
• Organization and priority setting
• Interpersonal relationships
• Patient-centered/relationship-based care
• Teamwork and collaboration with other disciplines,
patient and family


Actualizing the ARN Role

• Identifies and uses best practices to promote patientand family-centered care
• Identifies and resolves barriers to promote safe handoffs, interdisciplinary collaboration and efficient
throughput of patients
• Ensures, with Attending MD, that patient care meets the
unit’s clinical standards
• Develops and revises the patient care goals with the
clinical care team daily



• Coordinates meetings with clinicians for timely
decision-making and optimizes handoffs across
the continuum
• Communicates with the patient and family,
discusses plan of the day, etc
• Serves as a role model for interdisciplinary
problem-solving
• Transmits all key information to covering
clinician(s) in an efficient, comprehensive
manner when handoffs are required



• Organizes twice daily care team huddles
• Meets with family on a continuous basis
regarding plan of care, disposition, goals of
treatment, palliative care, end of life issues
• Meets weekly with all members of the healthcare
team to design, coordinate and evaluate the plan
of care


The ARN Scope of Practice

Massachusetts General Laws, Chapter 112, section 80B defines the legal practice
of nursing in the Commonwealth as,
“Those services which assist individuals or groups to maintain or attain optimal
health. Nursing practice requires substantial specialized knowledge of nursing
theory and related scientific, behavioral and humanistic disciplines…
…Nursing practice involves clinical decision making leading to the development
and implementation of a strategy of care to accomplish defined goals…
…shall include, but not be limited to the performance of services which promote
and support optimal functioning across the life span; the collaboration with
other members of the health team to achieve defined goals; health counseling
and teaching; the provision of comfort measures; teaching and supervising
others; and participation in research which contributes to the expansion of
nursing knowledge.”



Massachusetts Board of Registration in Nursing
regulations at 244 CMR 3.01
interprets the law as,
• systematically assess health status
• analyze and interpret data; and make informed
judgments
• plan and implement nursing interventions
• provides and coordinates health teaching
• evaluates outcomes
• collaborates, communicates and cooperates
• serve as patient advocate



The ANA Code of Ethics for Nurses at Provision 7 states, “The
nurse participates in the advancement of the profession
through contributions to practice, education, administration
and knowledge development.”
7.1: Advancing the profession through active involvement in nursing and in
healthcare policy.
7.2: Advancing the profession by developing, maintaining, and implementing
professional standards in clinical, administrative, and educational
practice.
7.3: Advancing the profession through knowledge development,
dissemination, and application to practice.


The ARN Development

Dreyfus Model of Skill Acquisition
as applied by Benner to Nurses


The ARN Development

Stage 1: Novice
• The nurse at this stage has no experience
• Their practice is rule governed
• They must learn the rules to guide their actionsfollowing the rules is good practice
• They cannot yet grasp context-specific meanings
• Their practice is limited and inflexible because they do
not yet have the experience to draw on


The ARN Development

Stage 2: Advanced Beginner
• Feels secure with practice directed by orders, rules and
procedures or “common practices.” Feels they can rely on
protocols
• Multiple & competing tasks show up as an overwhelming list of
things that must be done
• They feel responsible for completing the tasks- engagement is
with the tasks
• Good day is defined as getting everything done
• Delegate up
• Focus on the immediate present
• In rapidly changing situations - misses subtle cues of problems


The ARN Development

Stage 3: Competent
• Characterized by increased organization and efficiency
• Mastery of technical skills
• Conscious deliberate planning
• Shift from managing the task to managing the patient


The ARN Development

Stage 4: Proficient

• Stage of rapid learning - the patient and their
needs are the focus
• Skill of seeing - narratives reflect overturned
expectations and seeing contextual and
situational changes that require actions other
than those planned or anticipated
• Recognize patterns of signs and symptoms and
their meanings
• Numbers gain meaning or salience


The ARN Development

Stage 5: The Expert
• Attention and actions are guided by the patient’s needs
and changing responses, and demands
• Fusion of thought and action
• Clinical forethought
• Fluid, skillful maneuvering in very complex and difficult
situations
• Intuition - direct understanding of the particulars of a
situation without conscious deliberation, awareness or
articulation


The ARN Future

The Future of Nursing: Leading Change, Advancing Health
1. Nurses should practice to the full extent of their education and
training.
3. Nurses should be full partners, with physicians and other health
care professionals, in redesigning health care in the United
States.
Conclusion
“The United States has the opportunity to transform its health care
system, and nurses can and should play a fundamental role in
this transformation.”

Ref: IOM, October 2010

The Attending Registered Nurse

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