An Introduction to Medical-Surgical Nursing

You start your shift with the following assignments:*

1. Ms. Smith, a 68-year-old who was admitted with a diagnosis of fluid overload. She has a history of chronic renal failure, hypertension, and type 2 diabetes. She will be receiving hemodialysis today in her room and is also scheduled for a 2-D echocardiogram.
2. 37-year-old John White, who was admitted with a diagnosis of appendicitis. He is scheduled for a laparoscopic appendectomy at 1300 hours.
3. Mr. Jackson, a 72-year-old patient with exacerbation of chronic obstructive pulmonary disease. He is oxygen dependent and has scheduled respiratory treatments throughout the shift.
4. Anne Brown, 48 years old, who was admitted with a cat scratch. Her left lower extremity is swollen, red, and painful. She is receiving three different antibiotics to combat the infection and cellulitis.
5. David Martin, 58 years old, who is one-day postoperative after a pancreatectomy for a pancreatic tumor. He has a nasogastric tube, Foley catheter, patient-controlled analgesia, peripherally inserted central catheter, and sequential compression devices. And you were just notified that you would be receiving Joseph Garcia, an 84-year-old with a diagnosis of altered mental status, from the Emergency Department. (*All scenarios, although seemingly real, are created; all patients described are fictitious.)

Who are you? Well, you are a medical-surgical (med-surg) nurse, of course. You are a member of a very talented and competent nursing specialty. Let’s delve into this in more detail.

Have you ever tried to define nursing to anyone? Chances are you’ve heard different descriptions from different nurses. Florence Nightingale (1859) stated that nursing “ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all at the least expense of vital power to the patient.”¹ The American Nurses Association defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.”² As you can see, the scope of nursing has really expanded from the time of Florence Nightingale.

How do you define med-surg nursing? Now, that becomes even trickier. Med-surg nursing is defined as “the diagnosis and treatment of human responses of individuals and groups to actual or potential health problems.”³ The goal of med-surg nursing is to assist the individual or group in promoting, restoring, or maintaining his/her optimal health. Some describe the practice of med-surg nurses as foundational to all nursing practice. Med-surg nurses can work in a variety of settings ranging from the hospital to the home to outpatient clinics. It can be argued that the med-surg unit is the most important department in an acute care hospital since the unit houses the most number of patients that can determine patient satisfaction scores.⁴

Is med-surg nursing really a nursing specialty or it is just basic nursing? The American Board of Nursing Specialties (ABNS) Accreditation Standards outlines several criteria for a nursing specialty⁵:

1. There is a unique and distinct body of scientific knowledge.
2. There is an identified need for the specialty.
3. The specialty must be defined, its core knowledge explicated, a scope of practice written, with the nursing component delineated, and standards for the specialty specified.

Med-surg nursing certainly meets the above criteria. These criteria are further refined and defined throughout the ABNS Accreditation Standards with med-surg nursing fulfilling the requirements. One of the criteria deserving particular notice states there should be the presence of a national or international organization with registered nurse members endorsing or supporting the specialty. The Academy of Medical-Surgical Nurses (AMSN) was established for the purpose of supporting and promoting the work of the med-surg nurse.

One of the ways AMSN has worked to support the role of the med-surg nurse is in the area of continuing education. Because of the complexity of the med-surg patient, evolving technology, and the advancement of health care reform, a commitment to lifelong learning is essential. Whether continuing education is obtained by attendance at conventions and workshops or through reading journal articles, AMSN has worked to provide those needed materials for the med-surg nurse.

Another step was to establish a certification exam that was developed based on the practice of the med-surg nurse. This has been accomplished by AMSN’s partnership with the Medical-Surgical Nursing Certification Board (MSNCB). Nurses can demonstrate expertise in their practice by completing the certification process. In the 2012 Practice Analysis/Role Delineation conducted by MSNCB, there were several interesting results. The sample size was 1,272 certified med-surg nurses (CMSRNs). The following results were from the respondents that did not have a master’s (or higher) degree:

• 52.5% had a baccalaureate in nursing.
• The average number of years in nursing was 17.2 years while the average number of years in med-surg nursing was 14.7 years.
• 76% stated that “staff nurse” best described their work.
• 81% have worked on an inpatient med-surg unit.
• 60% stated they spent their time in direct patient care.

These facts provide insight into the dedication, experience level, and educational background of the med-surg nurse. Other components of the analysis are used in refining the practice-based CMSRN certification exam.

Benner, Kyriakidis, and Stannard identified nine different domains of practice in acute and critical care nursing practice.⁶ Some of the domains that med-surg nurses participate in include: diagnosing and managing life-sustaining physiologic functions; assuring patient safety; making a case; and providing comfort measures. In 2012, MSNCB further expanded these domains for the med-surg nurse. Some of the additional domains include the teaching/coaching function, the helping role, and administering and monitoring therapeutic interventions.⁷ How do med-surg nurses practice these domains? Let’s look at a typical day.

What does a med-surg nurse do on a shift-to-shift basis? Nurses begin their shift by receiving a report or handoff from the off-going nurse. After report, the nurse will discuss the tentative plan of care with other health care providers. Time is next spent conducting thorough head-to-toe assessments and administering ordered medications. Med-surg nurses discuss care with physicians as well as admit, discharge, and transfer patients throughout their shift. An experienced med-surg nurse is able to identify subtle changes in a patient’s condition and alert the physician before rapid deterioration occurs. They also assist with activities of daily living, teach patients and families, and continually work with other departments to ensure safety and care. Typically, med-surg nurses will be assigned four to six patients at the beginning of their shift. However, it is not unusual that they discharge two to three patients and receive two to three new patients during their shift. And, don’t forget documentation of all these treatments and activities. As you can see, it is a busy shift.

The complexity of the patients, increasing care demands, and increasing regulatory demands push the med-surg nurse into new ways of thinking. In the future, the med-surg nurse’s role will continue to expand. The practice of the med-surg nurse demands skill and expertise in a wide variety of disease states, medications, and communication techniques, as well as the ability to work with numerous members of the health care team. The Institute of Medicine’s Future of Nursing report recommends that nurses should practice to the full extent of their practice.⁸ While some have interpreted this recommendation as addressing the advanced practice nurse, the intent of the recommendation was broader, including the practice of the registered nurse.

When considering the practice of the med-surg nurse, there is much that can be done in considering the full extent of practice. Often the clinical decision-making and work in care coordination by the med-surg nurse is not fully recognized. Med-surg nurses have long been involved in seeing the whole picture for the patient, looking beyond the patient’s immediate state to the steps post-hospitalization. The med-surg nurse has the opportunity to connect with the patient, the family, physicians, nursing staff, and the rest of the health care team. This provides an opportunity to make connections and carefully plan for the patients’ care as they recover from their acute state to a time of rehabilitation, whether in a facility or as they return to home.

In the accountable care environment, the role of the med-surg nurse will be key in providing quality care and preventing readmissions. The practice of the med-surg nurse is considered to be primarily in the acute care setting. The increasing complexity of patients in the home stretches the boundaries of the med-surg nurse’s practice. Nurses in long-term acute care describe their practice as that of a med-surg nurse. Other changes within health care may continue to stretch the practice settings and opportunities for the med-surg nurse.

The future will bring continued efforts to provide evidence that supports the work and the functions of the med-surg nurse. Nurses at the bedside are interested in discovering why the care they provide improves patient outcomes. Med-surg nurses seek to learn the most effective techniques that will lead to higher quality patient care. The care med-surg nurses provide is a rich source for future research.

As nurses at the bedside gain new skills and abilities, they become the expert and leader in their work setting. The med-surg nurse in the future will be the clinical leader at the bedside. This is an expanding role for the nurse. The clinical leader will be skilled in delegation, communication, conflict management and resolution, coordination of care among the interdisciplinary health care team, and working with multiple groups across the health care organization. The nurse will not leave the bedside to be a clinical leader. Rather, nurses will expand their scope of practice to include these important skills.

Med-surg nursing is for you if you: 1) like a challenge; 2) want to make a difference in the life of a patient; 3) want to expand your knowledge base, 4) are not afraid of hard work; and 5) want to work in a dynamic work environment. Med-surg nurses are critical thinkers, clinical leaders, and integral members of the interdisciplinary team. They show commitment by being connected and compassionate with others. Give this nursing specialty a try. The rewards are amazing!

References

1. F. Nightingale, Notes on Nursing: What It Is and What It Is Not, 1st ed. (London: Harrison, 1859), 6.
2. American Nurses Association, “What is nursing?,” retrieved August 27, 2012, from www.nursingworld.org/EspeciallyForYou/What-is-Nursing.
3. H. Cravens, Core Curriculum for Medical-Surgical Nursing, 4th ed. (Pitman, NJ: Anthony J. Jannetti, Inc., 2009).
4. R. Parsons, “Spotlight on Med/Surg,” retrieved July 6, 2012, from www.hfsconsultants.com/blog/spotlight-on-medsurg.
5. Accreditation Board for Specialty Nursing Certification, ”Accreditation Standards,” retrieved August 17, 2012, from www.nursingcertification.org/accreditation-standards.html.
6. P. Benner, P.H. Kyriakidis, and D. Stannard, Clinical Wisdom and Interventions in Acute and Critical Care: A Thinking-in-Action Approach, 2nd ed. (New York: Springer Publishing, 2011), 1-26.
7. Medical-Surgical Nursing Certification Board (MSNCB), Practice analysis and role delineation of medical-surgical nursing (Pitman, NJ: Anthony J. Jannetti, Inc., 2012).
8. Institute of Medicine (IOM), The future of nursing: Leading change, advancing health (Washington, DC: The National Academies Press, 2010).