Reflections of a clinical nurse

is it time for a nursing moratorium?

2008-04-27T14:33:00.004+10:00

Dragging myself to a shift has been a struggle for a while now, but I only realised the extent of my malaise when I sat down now to write - going back over my (rather sparse) posts, I discovered it was a way back in October that I first reported my almost decision to quit. That's six months of hating my job.

Attempting to be objective, I can see that it isn't necessarily nursing I hate. It's more a case of my ward environment getting me down.

Horizontal violence still lives - in fact it's kicking along quite strongly in my corner of the world.

When I first started on this ward I thought if I could put my head down, hive off to my patients and put in a good days work I might survive. I was wrong. More than wrong. I was seriously deluding myself. My work environment is slowly killing my passion for nursing and care.

All this became quite clear to me a few nights ago. I was working a late shift with a male nurse from the hospital's nursing pool. He had previously been employed on the ward, but a few months ago left to (among other things) escape the ward culture. As we chatted I found a different man - relaxed, pleasant, altogether transformed. When I pointed out his new found peace he detailed his journey to the edge and back. He too almost quit nursing because of the ward environment. Since leaving he has rediscovered his nursing mojo. Now when he works a shift on my ward he is appalled by the shallowness, nastiness, exclusivity and power games. I am not imagining things.

So where does this leave me? What to do?

Get out. Leave the ward. Find another work environment fast, before my soul is destroyed.

Easier said than done, believe me! In my corner of the world there is one public hospital (where I am employed) with four medical, two surgical, one paediatric and three women's health wards. Throw in a limited number of specialty areas (with often equally nasty nurses) and we're not talking a huge range of choice. Across town there are two private hospitals. I do not find the prospect of working under a bigger pump in an institution attempting to operate profitably the least bit appealing. A minor issue is that I would also lose the tax benefits offered to those who choose to stay in the public sector (to the tune of several thousand dollars annually).

One option is to return to the ward where I was previously employed, but I don't like orthopaedics. The mindless churning through of total knee and hip replacements is almost as soul destroying as bitchy work mates. Nursing pool offers some hope, but it doesn't really offer the stimulation I need - those medical wards are full of patients awaiting nursing home placement. Yes, they still deserve care but I'm a surgical nurse by nature. Endless cycles of bed baths and pressure area rounds don't appeal.

I'm almost stumped. Quitting nursing appears the only option... Unless...

Unless I take up my friend's offer of employment in the ORS. In my grad year I did a few months in theatre. Admittedly it's a big stretch from scrubbing independently for knee arthroscopy after knee arthroscopy to being a functioning, independent member of the team. But maybe that's just the stimulation I need! And I know there is good educational support.

So I might not quit nursing, I might just step sideways. I'll keep you posted.

the influence and power of being a nurse

2008-02-21T20:24:00.004+11:00

I have always felt the weight of the influence I can exert as a nurse in my sphere of the world - acquaintances sidle up to me and ask for advice on this or that ailment as we mingle at social gatherings; my emphasis on the importance of this or that medication contributes to patient compliance on discharge; a failure to stress the importance of chest physio or leg exercises or sitting out may make the difference between a complication free recuperation or not.

Conversely, what I say may make no difference at all. Which nurse hasn't experienced the mortification of educating a patient only to have them ask the doctor the self same questions? Of course when the doctor advises them of the exact same information we provided, they sit up and listen as if it is news they have never heard before and we, silly nurses, are left looking incompetent and uninformed.

What fascinates me is the subtlety with which a person can be swayed. A couple of weeks ago I was looking after a patient who needed significant rehabilitation, but he had no insight into this. In fact, because he was improving physically he was convinced he was ready to discharge straight away. He repeatedly asked why he could not leave today and I repeatedly advised him of the need to wait for a place in the rehab unit in order to ensure he was fully ready for discharge. He wrestled with the constraints of the delay, but with constant redirection he could be reminded of how useful waiting would be. His wife backed me up in reinforcing the situation.

The next morning another nurse sailed into the room, listened to the patient's pleas for discharge and, before providing any care in terms of assistance with daily living or observation of mental capability, decided he could see no reason why the patient could not be discharged. The next thing I knew the patient was surrounded by his four young children advising me he was going home to be with his five children. The children stared rather strangely at him, because in truth there were only four of them, but they still smiled with shy joy, for dad was finally coming home. Suddenly occupational therapists, physios, doctors and the charge nurse were all milling around trying to ensure the patient would be well supported at home despite his decision to discharge himself against medical advice. The patient was discharged into his wife's care with a full range of community support in place.

I can't help wondering what role the patient's allocated nurse played that day. When I cared for the patient the day before there had been no talk from the wife or the patient of going home immediately. We continually steered the conversation back into the safe waters of rehabilitation. What did that nurse say that day to convince the patient he might succeed in his quest to go leave hospital?

I was so curious about this I actually challenged the nurse about his actions and comments to the patient and his wife. He looked wounded as he defended himself, assuring me he had said nothing that might be construed as encouraging the patient to discharge himself. But I am not convinced - nurses have influence, patients listen to what we say. They observe our actions, they notice our attitudes and they make decisions with this in mind. That nurse only needed to imply agreement with the patient's readiness to discharge and it could have been enough to convince him to pursue the option.

Two weeks on, I wonder how he's going, the too-soon-discharged man. Is his wife coping with the demands of someone who in all truth needed rehabilitation? What impact is his early departure from hospital having on those four young children?

Maybe I will never know, but one thing I am sure of is this - what I say makes a difference to my patients. Whether I like it or not, a great deal of power is vested in my status as a nurse, and with that power comes the responsibility to work through the implications of my influence for a patient's good or bad. It would be beneficial if I used my power wisely and carefully in order to achieve the best outcomes possible for those entrusted to my care.

oh what a night

2008-01-09T20:32:00.000+11:00

Disclaimer: Please stop reading now if you don't deal well with death or have lost a loved one recently. There is probably another blog more suited to your needs right now and I urge you to visit them rather than linger here.

*********

Call me good or (philosophical debates aside) call it luck, but in my twelve years as a nurse I've never had a patient die unexpectedly while under my care. Of course various patients have died along the way, but their deaths were relatively peaceful and anticipated and I was able to offer comfort and dignity in their last moments. I find these ministrations rewarding and meaningful and I don't shy away from them. For me it is an honour to be there in a person's final hours.

Still, it came as something of a shock to find a patient obviously dead at 4am last night. I knew the moment I stepped behind the curtain, but as she was still listed for resuscitation I had to respond to the emergency and call a code. She'd been unwell for some time and we could not revive her. As we pulled up the sheet and recorded the time of death our heads were spinning. Night shifts run on skeleton staff so there was no chance to sit with the patient and pay our respects. It was immediately on to the tasks left undone during the emergency.

At 5am I helped turn a patient and was not happy with her condition. She had deteriorated significantly during the course of the night so I asked the doctor to come and review her. At 6:15am we called another code. After 15 minutes this patient too was declared deceased, in the bed right next to the first patient. Again there was no time to contemplate, reflect, or honour the long, full life of this patient. We had little choice but to madly try to complete our duties before the morning staff arrived.

The whole episode seemed quite surreal. Two patients in one night, right next to each other? Unheard of, at least in this small place. Then there was the automatic defibrillator that kept telling us in a mechanical voice to stop CPR while it analysed a heart rhythm we knew did not exist. As I shut the lid to silence it, the strident voice called out 'open lid to continue CPR' and we couldn't help but laugh wryly at the incongruity of the situation. Then there was the nurse on another ward, who could not have failed to hear the code called over the hospital PA, but still kept phoning and asking for assistance with a relatively minor problem they had. Things became more absurd when other patients, oblivious to the mayhem, buzzed for blankets, bed pans, clean sheets, panadol. I stared at them dazedly - blankets, bedpans, clean sheets and panadol in the midst of pandemonium as we attempted to cheat death? I dished out requests quickly and quietly, asking for patience as we sought to recover from each crisis.

When the night finally ended we four nurses ducked down to the local cafe for a drink and debrief before heading home to sleep and do it all again tonight.

Only I'm not doing it again tonight, because as it turns out I couldn't sleep. I kept seeing the dead, pondering what we did, wondering if we could have done more as my heart raced. Calm balm, soothing music, reading to tire me out... nothing worked. I repeatedly dropped off to sleep for a few minutes before waking with a start and returning to the night's events in my mind.

So while I seemed to cope at the time and accept the patient's deaths (they were old, unwell, one can't keep people alive forever), the emotional toll played out in my head today. What a terrible way to die. What an indignity. What a miserable end. And what of the families, rudely awoken with the sad news? And the other patients in the room who endured the events behind rustling curtains? Unpleasant. Disturbing.

Twelve years code free, but what a horrible way to end the run. Miserable. Unpleasant. Hideous. I know it had to happen some time, but I'd like another twelve years event free. Please.

checking out - checking in

2007-10-26T07:59:00.000+11:00

I checked out of blogging for a while. (That's not entirely true - my personal blog has been going great guns) Anyway, sorry about that.

The more serious issues is that along the way I nearly checked out of nursing too.

I finished working as a Clinical Support Nurse at the end of April and returned to the ward environment. Well, I had never really left the ward environment, but I returned to the hard labour of being the one doing the work rather than supervising and observing others doing the work. I hated it and wanted to quit. While I was trying to find my feet and get my time management back on track I kept getting landed with student nurses and I just couldn't seem to get myself together. (Interestingly, now that I'm flying again I hardly ever am allocated students!)

Somehow nursing seemed little more than a list of tedious jobs I needed to get through by a certain time. Then I could go home. And put my tired, aching feet up and dream of leaving nursing. I mean, mixing up and pushing antibiotics into a cannula - where's the art in that? For me, nursing is all about caring, but all I seemed to be doing was cleaning up excrement and a host of other menial tasks.

None of us like change, and adjustment is uncomfortable, but eventually we get there. As did I. After about two months something clicked. I started to love my job again. Nursing took on new meaning. I cherished my interactions with patients and families in crisis. I saw where each task fitted into the overall picture of caring. I checked back in to nursing.

And now I'm checking back into blogging about nursing. Here's to many reflective posts on nursing in general and my practice in particular!

what's the point of policies?

2007-04-24T09:43:00.000+10:00

I left work feeling quite discouraged the other day, just wondering what's the point of it all. Why do I even bother encouraging graduates to demonstrate excellence in their practice? Nobody else cares. Why should I? (Broad brush strokes, broad brush strokes!)

In two short weeks I will no longer be a graduate support nurse. Instead I'm moving back to shift work on a general surgical ward. Before I make this transition (can I have a support nurse for myself please?!) I'm trying to work a day with every graduate RN in order to write a comprehensive assessment of their practice for the clinical educators who will take on my role. It's been quite an eye opener!

As usual, there's a broad range of competence. Some are the most amazing graduates I've come across. Thorough, well informed, good skills. A few practice in a way that is altogether too risky for my liking. They consistently select patients outside of their scope of practice and make mistakes because they're not quite sure what they should be doing. One or two are just plain careless. They drift through their day without paying a great deal of attention to anything and they certainly aren't interested in doing anything properly.

It was a slap dash, careless graduate who sparked my outburst at the beginning of this post. For once I mastered the art of standing back and letting them do the work while I observed. How very revealing! By the end of the shift any pressure area care was only performed at my desperate suggestion; those requiring assistance with hygiene were simply not washed; and huge slabs of time were spent defending why this or that policy was not being followed in their practice.

Come knock off time, I was infuriated. What a cheek, swanning into nursing and refusing to follow policies and protocols because after two months of practice they deem them an unnecessary hindrance?! The arrogance.

I was so angry I couldn't stay around and give the graduate any feedback. I needed time to calm down, gather my thoughts and form a measured response.

As I debriefed with a colleague I realised the graduate is not the only one at fault here. One of their stated reasons for not following policy is that 'nobody else does'. Here I am running around highlighting policies, reviewing protocols, urging professional practice while at the same time a host of other nurses are running around breaking policies, ignorant of protocols and role modeling unprofessional practice. What hope does this or any other graduate have of developing professional work habits? Why should they follow the policies when no one else does?

And here I come to my question - what's the point of policies? Why have them? We can all get along fine without them!

"See, I just moved the patient up the bed without that simple lifting device, and did I hurt my back? No!

"And what about giving an injection without gloves? I didn't sustain a needle stick injury!

"Did I give the medication to the wrong patient when I didn't check their hospital number? Of course not!

"Where's the wound infection in the patient who I failed to maintain asepsis with?

"I didn't splash myself in the eye when I didn't wear protective goggles to remove that drain!

"Get over yourself Muse! Stop pushing policies onto me that I just don't need."

Stated like that they do seem like silly, insignificant things. Maybe I should just get over myself and stop obsessing over every broken policy. Maybe it doesn't matter. We're all doing fine without them.

But it does matter! Policies are there for a reason. (I'm such a rule follower) Somewhere, sometime, something terrible happened enough times that a policy was drawn up to protect patients, and to protect nurses.

We can't just ignore policies and protocols because they are inconvenient or slow us down. We can't rebel against the machine because we don't like somebody telling us how to practice. And we certainly can't let our standards slip because everybody else has.

Take a stand, make a difference. For yourself and for the patient!

I don't have much longer to teach graduates the importance of policies, but soon I'll be on the ward working beside them as one of the staff. My goal? To be a role model who does practice professionally, and who does follow policies. We're sunk if we don't!

violins and nursing errors

2007-04-03T21:45:00.000+10:00

I had a violin lesson with my teacher this evening and, in between the making of music, our conversation turned to teaching methods. Strangely I found a parallel between this and nursing.

As a child I learned the piano, and I remember practicing long and hard in order to attain the 'tick of completion' on a piece of music. This was no easy task, requiring nigh on perfection, at least in my mind. Since I commenced learning the violin as an adult I've noticed 'the tick' is much easier to attain - despite playing far from perfectly, my pages of music are littered with golden ticks!

I decided the difference lay in being an adult learner. Adults have little time to practice long and hard, so the teacher awards 'the tick' more liberally in order to prevent us from becoming discouraged. When I floated this idea past my teacher she laughed and explained the real reasoning behind the liberal tick.

When learning violin there are many techniques to master. As a student plays a certain piece of music, their performance sits in the context of their overall progress. It is unrealistic to expect a beginner to play perfect music when they are only just beginning to manage basic techniques. 'The tick' indicates that, in view of their evolving mastery, they are playing the piece to the best of their current abilities. Perfection is not the goal, only continuing development.

My teacher's explanation struck a chord with me, since the principle has relevance to evaluating the practice of graduate nurses.

Recently I observed a graduate making a significant error in their care of a patient, since their actions were in direct contravention of medical orders. I rectified the problem and educated the patient before speaking with the graduate. They struggled to explain the incident since they had not realised they were doing anything wrong until I came into the room.

Admittedly when I make an error on the violin I do not place anyone at risk, where a clinical error can have grave consequences. But putting this aside, along with the fact of the graduate's failure to work within their scope of practice, and their lack of responsibility for their actions, I have begun pondering my response to the situation.

On the surface I remained calm and measured, reassuring the patient and educating the graduate. Internally, I was exasperated: How could they not have known about this? What a terrible graduate they are to make such a mistake! Can they be trusted with anything? How poor is their clinical knowledge?

Right at this point I need to take a leaf from my violin teacher's book. Let's put this incident in it's proper context! They are a graduate - they're new, they're learning, and chances are, if they've never seen something before, they don't know about it! Cut them some slack. (Remember we're ignoring the fact the graduate should have known their scope of practice and not stepped out of it!)

Just as I am on a journey towards becoming a violin virtuoso (allow me to dream), so this graduate is on a journey towards becoming an experienced practitioner. Along the way we both make mistakes. Just as my teacher encourages me with the golden tick, so I am to encourage the graduate and congratulate them upon their successes. At the same time I can teach them new skills, helping them to develop.

I feel challenged to broaden my outlook on graduate mistakes. It would be helpful if I overcame my initial judgmental reaction, instead seeing each graduate in context, seeking to nurture them, and valuing the whole of their practice.

I did speak further with this particular graduate, explaining my concerns, feeding back on excellent aspects of their practice and encouraging them to know their limits and ask more questions! The patient is fine and all is well. I shall continue to learn the violin and the graduate will continue to develop their practice, and over time we will both move closer to perfection.

welcome to nursing

2007-02-21T16:20:00.000+11:00

The year is nearly two months old, but in some ways I feel as if my working year has just begun! The 2007 graduate nurses are out on the wards, and I have the task of smoothing the path of another cohort as they ease their way into the workforce. The graduates are all excited and jittery and earnest in their efforts to be a good nurse. I am smiling and encouraging them in an effort to provide good support.

They might be anxious and apprehensive, but I’m delighted to see them! Last year I let myself slump into a malaise – I don’t really know what I did for the last six months. Nothing?!

The extent of my slackness became evident when I was asked to provide a referee report for a graduate. When I sat down to gather my thoughts and write I could remember lots of pleasant chats, but recalling their practice?… I couldn’t! I know I observed them, answered their questions, provided supervision and direction on a number of occasions, but I can’t remember anything specific about their practice. When I consulted my notes – I found a few scribbles here and there in my diary. No formal evaluation, nothing!

If that was the only evidence of my slump it wouldn’t be too bad, but there’s more! The 2006 graduates are in the process of completing their practice portfolios. They’re racing around asking for signatures here and there, making last minute records and squashing 12 months of reflection into one week. I know they’re responsible for their own development – but didn’t I check their progress towards completion of the book and spur them on to professional growth? Nope.

And then there are the interviews where I sat with the graduates and preceptors to provide clinical feedback. Same as the referee report really – what can I feedback when I haven’t observed much of their practice? “You’re doing well. You have good skills. You’ve made progress over the last year.” Great. That’s really useful and meaningful feedback that will definitely help them develop greater competence. Not.

I don’t know what I did for the last six months – whatever it was, it didn’t amount to much. My body might have been at work everyday, but my mind was elsewhere.

What a relief that the 2007 graduates are here – this is my chance to make amends. With this new group I can start afresh, enthusiastically and energetically supporting them, observing them and recording everything I see and do! When it comes time to report on their progress I’ll be armed with all the information I need.

Welcome to nursing, graduates of 2007! Welcome back to nursing Muse!

oops. medication mismanagement.

2007-01-17T12:44:00.000+11:00

The other day I realised I had made a grave error in my evaluation of a graduate’s practice. Actually my mistake was even more elementary than that – I evaluated their practice but did little to follow up on my assessment.

Six months later it has come back to bight me!

Six months ago I observed a graduate make a medication error. I pulled them up, they rectified the problem, we discussed the importance of careful checking during medication administration and the graduate stated that they would slow down when giving out the pills. All was well.

Time passed, and somehow I never got back to observing the graduate’s medication practices again. Perhaps I saw them dispensing Panadol or Nexium as I passed through; maybe I stood beside them as they checked a patient’s armband; but I didn’t consistently stand and assess their medication management from start to finish. They were so self-assured and confident of their practice, advising me that of course they were careful. Their preceptor advised me that they had not noticed any problems with the pills. So I laid my concerns aside and moved on to other issues. Problem solved.

How wrong I was!

It’s January and graduates have a few short weeks left in which to complete their professional portfolios. They are running around in a final flurry of activity, scrambling to write episodes of practice and achieve all their learning objectives. Every year it is the same, and I am inundated with calls for assistance – ‘please can you sign me off on this. And this. And this. And, oh, there’s also this one!’ In my kind heartedness I spend as much time with them as I can and try and maintain impartiality in my assessments.

The graduate of this post had not been signed off on - you guessed it - medication management, so I agreed to observe her in practice and make my assessment.

That was when it happened.

Again.

Another wrongly dispensed medication. Another near miss that I had to point out. Another hasty correction. Another discussion about the importance of careful checking.

Sigh.

Here they are at the end of their graduate year, and still making the same mistakes as they were at the beginning of their placement. And how many more unidentified mistakes have they made in between?!

Of course the graduate must take responsibility for their lax practices and errors, but shame on you muse, shame. You could have done something about this and didn’t. You too must take some responsibility for this situation.

debunking the myths, revealing the truth

2006-12-14T16:30:00.000+11:00

In my position I’m frequently asked how to perform procedures and I’m especially asked how to perform procedures that aren’t found in the Nursing Practice Standards & Guidelines. One such procedure is the removal of CVCs.

Each time somebody asks me how to remove a CVC I run through the same process:

· Ask the patient to lie on the bed
· Wash your hands using the ‘asceptic hand wash’ procedure
· Remove the dressing
· Cleanse the site as per the Guideline for changing a CVC dressing
· Remove the sutures
· Ask the patient to take a deep breath and hold it
· Gently remove the CVC, checking that the tip is intact
· Place pressure on the site for at least a minute (the patient can breath again now)
· Cover the site with an occlusive dressing
· Dispose of your sharp appropriately
· Place rubbish in correct receptacles
· No, we don’t routinely culture the tip in this institution

Easy, except that every time I got to ‘ask the patient to take a deep breath and hold it’ and explaining the rationale of intrathoracic pressure preventing an air embolus I was plagued by the niggling doubt that this could just be an urban myth. One of those nursing traditions passed along by word of mouth for time immemorial. I had never seen this written down anywhere – I was just going by what I was taught 10 years ago when I was a novice nurse.

Yesterday another person approached me. “I can’t find a protocol – how do you remove a CVC?” I ran through my spiel and decided I couldn’t do this one more time without knowing for sure if the deep breath was really, really necessary. After I’d supervised this CVCs final moments of usefulness I did a search and – hey presto… the deep breath is REALLY, REALLY necessary!

Dong et al (1998) report that “after the removal of CVCs, a short track between the skin and the vein, about 2.5cm, may be formed and stay open for a brief moment. This track, formed with a 14-gauge catheter, can transmit about 200ml of air in a second…”

Yes I typed that correctly! 200ml air in a second. Woah.

Further digging revealed that it is the intrathoracic pressures on inspiration that make this most likely to occur. By having the patient take a deep breath and hold it (Valsalva manoeuvre) the pressures are greater in the intrathoracic space than in the atmosphere, so air is less likely to enter the vein and cause an air embolus. If a patient cannot hold their breath, the safest way to remove the CVC is on expiration (Peter and Saxman, 2003).

I discovered that not only is holding the breath during the removal of the CVC important, it is also helpful if the patient holds their breath between releasing the pressure and applying the occlusive dressing, betadine ointment provides a seal that prevents air entry through the CVC track, and the patient should lie in bed for at least 30 minutes post removal.

All that for one procedure we perform all the time with little thought! I’ll be giving a copy of these articles to everyone who asks me for advice on CVC removal!

This has been a positive experience for me. Not just because I found good information that helped me sort myth from truth but because it’s opened my eyes to all the other simple, frequently performed nursing procedures that are shrouded in myth and tradition. Is there a good reason for all of them too?

I’m on a mission to debunk the myths and reveal the truth in order to provide evidence based practice whenever possible!

Dong et al (1998) “The CVC removal distress syndrome: An unappreciated complication of Central Venous Catheter removal” in American Surgeon 64(4), April, p344

Peter and Saxman (2003) “Preventing Air Embolism When Removing CVCs: An Evidenced-Based Approach to Changing Practice” in MEDSURG Nursing 12(4), August, 223 – 228.

offering best support through questioning

2006-11-22T12:35:00.000+11:00

My recent musing has been around the subject of questioning for assessment.

Hand (2006) suggests that questions elicit evidence of competence that is not observable, by evoking a verbal response from the learner. It’s a valuable way of determining the level of knowledge a learner has, and identifying their understanding of events and interventions. Questioning rounds out the assessment picture, allowing for a more holistic and integrated review of learner competence.

Obviously questioning is important in the whole process of assessment, but I have had a wavering commitment to it. If you tracked on a chart my questioning history, the line would start high, indicating lots of questions being asked, before dropping down as the number of questions reduced, and right now the line is on the rise again as I recognise the need to incorporate questioning into a well rounded assessment plan.

Thinking back over my questioning history in this way is helpful. When I started this job I asked a lot of questions – I wanted to know what the graduates knew and what they thought about their practice. I wanted to identify knowledge deficits in order to help them develop a learning plan.

Understandably the graduates were uncomfortable with being questioned. They felt that since they had already qualified to be a registered nurse they no longer needed this level of scrutiny. I also began to feel uncomfortable – my position is one of clinical support and somehow giving the graduate the third degree in questioning didn’t seem appropriate support.

I stopped asking so many questions, but my evaluation of the graduates’ progress decreased. Thinking back to my last blog, I’ve come to realise that if my task is to monitor the quality and quantity of learning that has taken place in order to develop appropriate learning plans (which it is!), I simply cannot do that without asking questions. In order to offer the best clinical support, I must practice questioning.

Now I have come full circle, and I am gradually getting back into the groove of questioning, though I still find myself easily put off by the attitude of the graduates and the busyness of their day. I have to push through these obstructions and do what must be done not what feels good!

An incident the other day highlighted the issues here – the importance of questioning and the pressure not to question.

A graduate was working in a room with four patients, and one patient had two intercostal chest tubes (ICT). From experience, every graduate stumbles over the same issues with intercostal tubes every time, so I sidled up to this particular graduate and asked how they were going with the ICTs. They said they’d been looking after them for a few shifts now, and were OK with all that needed to be done. Since the graduate was obviously in the middle of a busy moment, I advised them that I would return soon and we could go through the ICT together.
Later I returned and pulled out the ICT observation chart and asked the graduate to explain what each observation meant. When we came to ‘air leak’ they started talking about checking the tubing for air leaks and noted that there had been a hissing coming from the suction connections the previous day. I then asked them if ‘air leak’ could refer to anything other than the tubing and when they didn’t know I took the opportunity to educate them correctly about ICTs and air leaks. This task was made more difficult because someone else had already ‘educated’ them about the ICT, so when I came along informing them that the original education was incorrect, they were somewhat dubious.

We continued to discuss ICTs, correct observation recording and other relevant protocols and the graduate continued on with their day. I walked away from the conversation suddenly very aware of the value of questioning. If I had merely looked at the completed observation chart, or taken the graduate’s word for it I might have missed the learning needs they had.

I’ve come away from this experience with a greater appreciation for the role of questioning in supporting the graduates. Now my task is to look at ways I can ease back into more thorough questioning - ‘How are you going today?’ and ‘Can I help you with anything?’ don’t really count!

I want to be the best Clinical Support Nurse I can, and questioning will help me better assess and provide support on the wards.

educator not policewoman

2006-11-14T16:30:00.000+11:00

I’ve decided to observe the bluffing graduate (of previous post fame) a little more closely. That combined with asking experienced staff for feedback has been enlightening. It really is bluff and bravado being put on show – there are some significant deficits in the grad’s practice.

Yesterday I hung around them for a fair bit of the shift, assisting and generally keeping an eye on what was happening. A lot appeared to be happening, but somehow not much got done! At least some of the essentials didn’t get done.

How to approach the problem? How to raise it in a sensitive manner that was constructive and helpful? Last week those were my big questions. The first thing I had to do was work myself up to even speak with the graduate – they irritated me and I would quite happily have ignored their issues and left them to their own devices. (Yeah that’ll work!)

Yesterday I forced myself to pop by and happened to find the grad in a bit of a pickle. Every time they tried to attend to a task, a patient would deteriorate and need quick intervention, or some other interruption would occur. They were getting behind so I offered to help.

In that moment their whole attitude changed – they were appreciative of my assistance, and after dealing effectively with a bradypnoeaic patient, suddenly they seemed to have more respect for me.

As their attitude towards me changed, my attitude towards them also changed. I decided that the kindest thing to do was inform them that I had heard some less than favourable feedback, that my observations had confirmed this, and ask how they would like to approach the situation.

It worked! At the end of the shift we got together for a chat and the graduate opened up. They accepted the feedback, almost tearfully acknowledged their problems, and admitted to a large dose of stress. Somehow they’d become so focused on completing a tick list, that their patient care had suffered - they were so intent on achieving certain competencies that they let the basics slip.

What a relief – for me and them! They were able to share the burden that their sliding practice was placing on them, while their openness allowed me to offer support and suggestions for change.

It all reminded me of something I read in a book by Ci Ci Stuart (2003). She wrote that:

Monitoring progress is not about policing the learner. It is
very much about finding out the quality and quantity of learning which has taken
place and any difficulties the learner may be experiencing so that further
learning activities can be discussed and planned for further learning and
development.

I’d been approaching this from the perspective of policing the graduate – “you aren’t doing this and you should be. Get your act together”.

When I decided to be honest and discuss how the graduate could best learn and develop, my attitude became more supportive and understanding and they were able to receive my feedback and discuss it honestly.

Our meeting ended on a good note. I ticked off some competencies for them, and we developed a plan for improvement.

And the bluff and bravado? One big cover up by someone who just needed to be understood and supported. Next time I’ll take the supportive approach from the start!

bluff or brilliance - assessment that is more than skin deep

2006-11-03T11:26:00.000+11:00

I’ve been reading an article about assessment of clinical practice (Chambers 1998) and it’s left me feeling quite encouraged. It isn’t just me who has problems with how best to assess – no one really has a clue about the best way to provide reliable and valid assessment in the clinical setting! Admittedly this article is from 1998 and more thought has gone into the topic since then, but here is a literature review that cannot describe the best way to assess nursing practice.

One interesting point in the article is that many nurses feel that overconfidence of a student or beginning level practitioner suggests unsafe practice or incompetence.

I’ve been caught out by this one before. It was only towards the end of one graduate’s six month placement that I realised their practice was based on bluff and bravado. They seemed to know the answer to lots of questions, or at least their withering tone of voice suggested they knew everything (“do you really think it’s necessary to ask me these questions when I obviously know the answers?!”). However in the cold light of day, their practice wasn’t up to scratch. By the time I finally saw through the bluff and recognised their incompetence it was too late - they only had a week or two left on the ward.

Interestingly I have an overconfident graduate under my care at the moment. Again they are full of answers, but in this case they are also derisive in their attitude to more experienced staff on the ward. I’m continually hearing about the way other nurses don’t know the answer to any of the questions they ask. I suppose the good thing is that the graduate then sniffs out policies and procedures to find the answer for themselves – but it’s the attitude that bothers me. It’s almost as if they feel invincible – “I don’t trust anything anyone tells me because I must find the answers on my own”. No one in nursing is invincible – we all come a cropper with some silly mistake at some point, usually when we thought we were most invincible!

This particular graduate is only half way through their placement, so I have time to investigate and intervene. I’ve worked with them once, but because I struggle to stand back and be a detached observer I’ve not seen what they do when working completely independently. I think it’s time to pull out my best observer skills and seek out the truth of what’s going on here. Are they competent or are they employing a clever ruse?

Here I come to accurately assess exactly what this graduate is up to.

The article mentioned here is:
Chambers MA , 1998, "Some issues in the assessment of clinical practice: a review of the literature" in Journal of Clinical Nursing 7, 201-208

addressing personal inadequacies to better assist others

2006-10-24T11:37:00.000+11:00

Once again I’m feeling miserable about this job. I feel as if I can’t do it, I don’t know what to do, I’m not supporting the graduates sufficiently, I should stop pretending I can do the job and make way for somebody else who really can. I’ve been sitting staring blankly at my diary, trying to figure out a way to change my situation, but mostly just feeling dejected and wondering why I’ve circled back to this place again. I think there are a few things at the root of my unsettled feeling.

I’m still finding my way in terms of how best to support graduates. The longer I puzzle over this, the more I realise that there is no one answer to this great dilemma! Every graduate is unique, individual, different. It would be futile to approach each RN in the same manner and offer the same support. The key to success is to individually assess the graduates and tailor support to their individual needs. It’s hardly rocket science, but when one starts out in a new area a simple formula for success is highly desirable. It’s unnerving to realise that there is no simple formula and no easy answer. The only solution is to approach each situation with an open mind and respond to what is in front of you.

Recently someone I know applied for and was offered an educator position in another area of the hospital. I’m excited for them, because they have worked hard to reach this place and they deserve the position. (Congratulations if you are reading this!) They are full of enthusiasm, as well as having a great grounding in education. I personally think they will do a fantastic job.

I think deep down I’m feeling somewhat threatened by this. Here I am with no specific training for my role, struggling to find the best way to do it, feeling ineffective and there they are with lots of skills and training and ideas. What if they do better than me and everyone sees how poor a job I am doing?

OK, a positive twist is that this person can be a resource and support person for me, and I can be for her in some ways too. We can help each other to be better educators.

Another source of angst is one of the graduates. They have been mildly verbally aggressive in their approach to me, bombarding me with complaints - the graduate program is not very good; they aren’t given opportunity to express their grievances regarding the program; and they are not being supported in achieving their goals. They constantly point out the faults in other people’s practice, and blame their lack of progress towards objectives on the system and thus on me. This all comes on top of their initial comment when we met that I was ‘very young’ – ie you aren’t old enough to do this job properly and I’m not going to respect you because of your age.

Their manner immediately gets my back up – I don’t appreciate the aggression and they win no favours from me with that approach. I also don’t appreciate people who refuse to take responsibility for their own progress. And it might be worth them examining their own practice and looking for the faults there before they start slating everyone else.

Having said all that, their attitude has shaken me. Someone sees through my subterfuge! Their lack of respect has latched onto my lack of respect for myself and I feel small and insufficient.

This has to stop. I need to take some practical steps that will restore my faith in myself as well as improving my professional performance.

1. Rest confidently in who I am and what I bring to the position. Halt the feeling of being threatened by this graduate. Instead of reacting defensively, take the time to listen to their grievance and offer support.

2. Embrace the new educator and be delighted for their success. Offer my ideas and experience and be open to their ideas and experience and knowledge. Develop two way sharing with them.

3. Seek out knowledge. Read and research about assessment and education. Take time to reflect on my interactions with each graduate and identify support strategies that will work for them.

4. Above all be positive and encouraging to myself! I am my own worst enemy!

meaningful support in the quest for professional development

2006-10-09T15:27:00.000+11:00

I’ve been making a concerted effort to work with every graduate in the last few weeks. This allows me to observe their practice and provide feedback – something they don’t seem to get a lot of.

Each graduate is allocated a preceptor on the ward for their whole placement, but the reality of heavy workloads and differing rosters pushes observation and feedback to the side. The grads head into their room and get to work, and the preceptors do the same in their room.

Nobody really knows how the graduates are working, or whether their practices are excellent, fair or poor because there is no time to observe them in the nitty-gritty of care provision. Charts, nursing notes, patient comments and the questions they ask provide some insight into their practice, but it isn’t the same as observing how they work for a whole shift.

So at the risk of feeling a heel, I attach myself to a graduate for a day, follow them around and watch what they do. I pay particular attention to infection control measures, medication management, documentation, knowledge and application of knowledge, communication, time management and provision of care.

That’s a fair bit to take in, and when I’m also trying to keep up with the patients’ conditions and needs it all becomes a little overwhelming. This is compounded if a graduate is struggling – I become very frustrated when I identify needed interventions that the graduates do not recognise or do not consider a priority. Often it is easier to intervene myself rather than talk them through the assessment, prioritisation and intervention required. Best case scenario when I step in is that they view me as a role model worth observing and learning from. Worst case scenario, the graduate feels undermined and demoralised when I hijack their plans for the day. It’s a tricky one – sometimes the day is very busy, and talking it through just takes too long. The patient needs action NOW so I take the speedy option and takeover their care for a moment or two.

Recently one graduate in particular found my intervention unhelpful. I had arranged to work with them for the day, and turned up after the shift had commenced. Things steadily became worse as the day progressed – time management was almost non-existent and the graduate missed IV medications, failed to complete fluid balance charts, omitted important observations and didn’t document care in a timely manner.

I stepped in and did quite a bit of the work and made suggestions to the graduate. At the end of the day they were disappointed with their performance as well as feeling that I had invaded their working space. If my role is all about support then for them to feel so demoralised, I mustn’t have provided much!

It was a revealing moment. This tactic didn’t work with this graduate. Sometimes it does work (and is absolutely necessary for the patient's wellbeing), but in this situation it was all wrong. This grad needed me to stand back, leave them to work their own way, intervene only when absolutely vital, and provide feedback on everything they did. We discussed this at the end of the day. I have since worked with this person again, and we had a much better day! They worked, I observed and they appreciated the feedback I provided.

One aspect of support is observing practice, making assessments and intervening appropriately. That means evaluating the intervention a graduate requires: What is their learning style? What support would they like me to give? How can I assist them in providing a high standard of care? Do they even need assistance, or should I simply stand back, observe and give feedback on their practice?

Lesson to learn – always ask the graduate what they want to gain from my presence! It might not match what I want to offer, but this is about them and meeting their needs. My task is to listen, identify their needs and tailer my intervention to their unique requirements. Then I will be providing worthwhile support that can help them develop professionally.

how to offer clinical support

2006-09-21T13:10:00.000+10:00

I’m struggling with how best to offer clinical support to graduates.

Which is a bit of a problem, seeing as my job title is ‘Clinical Support Nurse’. I’m supposed to be in there, helping the graduates develop, guiding and supporting them, assessing and providing feedback that will move them forward – not wondering how on earth to go about it!

I seem to travel around in circles. When I try and support the graduates by observing their practice, asking questions and providing feedback they complain that I make them nervous. Because of my presence they don’t nurse the way they usually would. The implication here is that my feedback is irrelevant since they wouldn’t normally make those mistakes. I’m only partially convinced on this one, but what can I say – having me in the room does change the dynamics.

Recently I listened to the graduate’s feedback, and adjusted my practice, taking on a friendly, supportive, 'alongside' role. Not that I wasn't friendly before! But now I don’t question them too much about their caseload; I give advice and make suggestions without expecting them to come up with their own answers; I educate about any unfamiliar interventions (did that before too!); I assist with the work as much as possible, hoping that they will observe my practice and learn by osmosis; I observe their practice very subtly and feedback gently. It’s all very nice, except now they complain that it’s confusing with two people working in the room – they can’t organise themselves properly. They want to be observed and given feedback about their normal practice!

What’s a clinical support nurse to do??!

I’m on the hunt now, for the best way to provide support in the clinical setting. Any ideas out there?

The professional precipice

2006-09-04T12:52:00.000+10:00

Have you ever had that moment of revelation, when you suddenly realise that you are walking dangerously close to the edge of a figurative precipice? One step further and you would be over the edge, falling into an abyss of your own making. All your best intentions cannot save you from the reality that you are not as noble and good as you once thought. An internal blackness you were not aware of has almost pushed you over the edge into a place you never envisaged approaching.

I had one of those moments last week. I was working with a graduate nurse when I observed her make a medication dispensing error.

Unfortunately this is not unusual – I frequently observe graduates making medication errors. Interestingly their excuse is nearly always the same. They blame their error upon my presence. They say that with me watching them they become nervous and forget to look up unknown medications, or they make calculation errors and dispense four tablets instead of two, or they mistake one drug for another. The power of a clinical support person is a little scary!

I pointed out this particular error, the nurse fixed the problem and the patient received the correct medication. A happy ending for all involved.

Except the story doesn’t end there. Our hospital policy dictates that all actual and near-miss medication errors must be reported. It wasn’t enough to point out the graduate’s error and ensure the patient received the right drug – I had to report this as a clinical incident. It’s a mean task and I don’t like it, but I'm required to do it!

I sighed deeply and asked myself if I really had to report this? On an imaginary scale of drug errors, this would have been minor. The patient would not have been harmed – they wouldn’t have received what was prescribed but it would not have resulted in any untoward event. And the graduate nurse was so nice. I’d pointed out her error, I’d suggested she slow down, pay more attention and check, check, check when dispensing medications, and she took this on board. What would it really matter if I didn’t report this?

And that was my precipice moment of revelation!

In Australia the Australian Nursing and Midwifery Council (ANMC) prescribe the competency standards that all nurses must work to. The regulatory bodies of Australia use these standards to determine a nurse’s competence and fitness for practice. I like to think I am not only a nice nurse, but that I am quite competent. If I held my practice up against these ANMC Competency Standards it would look good. Until last week, that is, when I realised that I was skimming dangerously close to the edge.

Competency Standard 2.1 states that I must “Practice in accordance with the nursing professions’ code of ethics and conduct.” This means that I must accept individuals regardless of race, culture, religion, age, gender, sexual preference, physical or mental state. I must ensure that my personal values and attitudes are not imposed on others.

I like to think of myself as a broad minded, accepting nurse – I don’t usually have a problem with following our Code of Ethics. Then I remembered a graduate I worked with last year. They had struggled with a number of clinical issues, and when the problems were pointed out they would not accept the assessment nor any advice, education or support. This was complicated by personality differences and it all became rather nasty. Consequently, if I observed the graduate making any medication errors I pointed them out and did not think twice about writing an incident form – it needed to be documented that this person was struggling.

So what was the difference between this situation and my current dilemma? Not much. I had observed both graduates making medication dispensing errors and they both corrected the problem prior to administering drugs to the patient. Hospital policy had not changed – in both situations I was required to report the incident.

The difference was that I really liked one person and didn’t want to report their mistake. The other person was difficult to work with so I had no problem reporting them. So much for practicing in accordance with a Code of Ethics! I was not wrongly treating somebody because I didn’t like them – I was wrongly treating somebody because I did like them. I wanted to protect them because they are a nice person.

I suppose this is only natural but it’s a bit shameful too. I cannot work in this job if I am so patently biased. This has been a wakeup call for me. Don’t be so concerned about being nice – be concerned about making accurate assessments and providing honest feedback. These graduates need people to be real with them. Their best chance at becoming competent is to hear about the fantastic things they do and to hear about the mistakes they make. Then they can grow and develop.

So I’ve walked away from the abyss, reported the incident and I’m making a commitment to being unbiased at all times in my support of graduates.

PDP

2006-08-28T16:25:00.000+10:00

As I’ve said before, feeling like an impostor is normal. Doing nothing to move on is the problem! Which is exactly the situation I’ve been in.

I’ve tiptoed around the wards feeling out of my depth, developed the art of avoidance, and hidden how uncertain I feel from the world. This in turn has left me feeling ineffective – I’ve never really mastered how to assess, educate and support graduates.

What I really want is to move on from this place, to develop the skills I need in order to offer excellent clinical support and to achieve a sense of fulfilment and satisfaction from the work I do. To facilitate this, two weeks ago I met with my boss to develop a professional development plan (PDP). It wasn’t all bad news!

We reviewed the positives of my performance, and I have to say I was quite pleased with what I have achieved! I relate well with the graduates and offer them moral support and encouragement; I write objective assessments that reflect the ANMC competencies; and I support the Graduate Nurse Development Program (GNDP) Co-ordinator by presenting education sessions and assisting with administration. On a personal level, I have undertaken 97 hours of continuing professional education! These are some things I can feel positive about.

On the down side, I have not pursued some issues amongst graduates and preceptors because I have felt afraid. Some graduates lap up every little bit of support on offer – they’re the easy ones to work with! Others don’t want help or information. They project an aura that says ‘leave me alone’. I find this intimidating, and sometimes I have not intervened when I have identified practice issues because I did not want to force my way through the graduate’s defences. Very nice of me, but what about the professional development of the graduate?!

At times I don’t confront issues because I lack confidence in my clinical skills. “It’s been a while since I worked on the ward,” or “it’s been an age since I worked in this specialty” – maybe things have changed and I’ve got it all wrong!

The PDP provided an opportunity to review these, and other problems, and to formulate a plan for progress. Here briefly are my goals for the next few months:

· Develop my personal clinical skills – supernumerary shifts on wards, time with the stomal therapy nurse, venipuncture with the blood sisters
· Improve communication – regular meetings with CNMs, attendance at ward meetings, improved communication with preceptors (newsletters etc)
· Increase knowledge of supportive practices – literature review of models and/or experiences of others in clinical education and support
· Regular reflection – online journaling and reflective episodes of practice

I feel empowered to change just by writing these goals! They offer hope for change. Now I need to put them into practice and see my dreams for professional development become a reality.

Confronting the nurse impostor

2006-08-07T16:33:00.000+10:00

Recently I read that women who move up into new positions feel like fakes. So common is this feeling it has been given a name - the ‘Impostor Phenomenon’. The upwardly mobile woman internally feels that she is a phoney who achieved her new status purely because of luck, rather than by her intelligence or ability. The literature goes on to say that this is not an abnormal feeling, but something that normal individuals experience when they transition to a new role that changes their identity and relationships. The woman gripped by the “Impostor Phenomenon” may suffer from anxiety, low self-confidence, depression and a feeling of disconnectedness. (Check out the full article at: http://www.medscape.com/viewarticle/533648) In another, now lost article, I read that this feeling can last for several months.

Help! I’ve been in this job for a year and still feel like an impostor! At times I feel that I achieve little, that I can’t do the job properly, that I should give up and go back to my own little patient load. I feel lost - aimless even. Surely there must be other people who can do this job better than I can?

It’s got to the point where I must quit… or take action! I’ve decided to take action, so today sees the launch of my plan that will put these ‘impostor gremlins’ to bed for good! I’m pulling myself together, taking responsibility for my development and taking control of my future. (Sounds good anyway!)

How, you may ask, will I achieve this?

First comes this blog with reflections on my development and plans for the future. Then a PDP on Thursday. I’ve also got some specific tasks that I’m putting into action (I’ll write more on them later)… things are looking up already - I will defeat the impostor within!