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Transition into Nursing Practice

Transition into Nursing Practice

The New Nurse: Strategies for Transition into Practice Assessment 3 Case Study

The New Nurse: Strategies for Transition into Practice

“Success is not final, failure is not fatal: it is the courage to continue that counts.” —Winston Churchill

Kelley’s story….

Night shifts are horrible, and anyone who says they don’t mind them is lying. I was on my third in a row and I was tired – the sort of tired where your eyes feel hot and sunken, and blinking takes three to four seconds, and you never knew a reflex could be so torturous. That night I had come into the ward and it appeared nothing had been done during the day. It was only the beginning of the shift and I already felt like I was so far up s**t creek without a paddle that I was off the map.

The night wore on and one patient was taking up a lot of my time. He had a groin abscess – I had admitted him the previous night and he had been very unwell. He had had a large amount of heroin and alcohol in his system, and his level of consciousness was the wrong side of sleepy. Now, however, he was wide awake and angry. Withdrawal from drugs or alcohol is painful and degrading; it’s not easy. That said, it’s not nice to be used as a verbal punching bag. 

It’s 4am and I’ve got seven patients, one of whom is acutely unwell, while another is following me around the ward demanding drugs I cannot give him. The other five have a range of problems. 

Mr groin abscess, when he isn’t following me around and swearing, is trying to smoke in the toilets on the ward, conveniently placed next to oxygen cylinders; he denies everything when we’re forced to call security.

Everyone is busy and I feel like I’m drowning. It’s now that the gods of the hospital decide to kick me in my already battered shins. There’s another patient coming up into the remaining bed. I eyeball her as she comes in. She looks all right. I take her history and her presenting complaint doesn’t sound terrifying.

I send the third year student nurse to do her admission – it’s common practice on my ward. An hour later and the student nurse is still going through the paperwork – nothing can be that wrong as the woman is fully alert, with no complaint of pain and talking normally. It’s 5.30am and I’ve just managed to sit down and start my notes. I see the student nurse and ask what the new patient’s score is – like most hospitals we use a scoring system that amalgamates clinical observations and tells us when to panic. We’re supposed to escalate a score of five and above.

This is ​the time​ when my “difficult” patient pins me against a wall, still demanding ​he needs ​his medication

The student replies that she’s scoring a six. This pisses me off as the student should have flagged this up as soon as she had got the score. I repeat the observations – she’s a six, almost a seven. I call the doctor; we reason that some of the alarming problems are normal because of her medical history. We deal with the temperature and the underlying infection, and leave the lady to sleep, with a promise that I will return in two hours to check on her.

This is when my “difficult” patient attempts to pin me against a wall, still demanding his medication. Dealing with the situation takes ages. It gets to 6am when all the morning jobs start. I haven’t told anyone that I was planning on rechecking my new lady but I reason that a nurse has been allocated to do the routine morning observations. The problem is that the nurse is also dealing with a tough crowd and doesn’t get round to my lady. By the time I remember, three hours have passed. I go to her and she’s in a bad way. I will never be able to articulate the feeling of looking at a patient who isn’t supposed to be dying and knowing that they are.

There’s a well-documented phenomenon called an impending sense of doom, often experienced as part of a quick demise or a sudden onset of fatal illness. This sweet lady looked me dead in the eye and said: “Something’s not right. Something is very wrong with me.” For a second I was paralysed with fear – she wasn’t breathing well, her heart rate was too high, her blood pressure too low, her oxygen saturation levels were dropping and she was confused. She was septic – people die of sepsis – nurses are supposed to recognise this.

I call the team. They are at a crash call one floor below. The nursing team is in handover – the worst time to get sick. My remaining colleagues spring into action and within 15 minutes we’ve got her on a cardiac monitor, given her oxygen, done an ECG, scanned her bladder, inserted a urinary catheter, given her all the medication we can, taken bloods and tried to reassure her.

The senior nurses are discussing whether to put “the call” out, well aware that most of the doctors are working on someone whose heart has stopped downstairs. I’m already an hour and a half into overtime at this point and am told to go home. When I get home I can’t sleep. I shut my eyes and I see the look in hers, silently begging for someone, me, to help her.

A colleague told me the lady was taken to intensive care. She is confident that she’ll be OK and that we did all we could on the ward. I am not. I call a friend who has never worked in healthcare, who is not a girl in her early 20s who just watched somebody the same age as their mother fight for their life and tried to fight with her. I cry for an hour and try to persuade myself and her it’s not my fault. I tell myself I was tired, that my colleagues shouldn’t have left me with so much to handle, that the student should have told me sooner, that there should have been more doctors around.

There can be no excuses when somebody’s life is at stake – it’s my job, it’s what I’m supposed to do. I need to be able to handle the confused, the aggressive and the very unwell. It’s my job to comfort and care, to organise and fix by watching and recognising, to listen and to always prepare for the worst.

I failed to do my job that night and a women nearly died. I suspect all healthcare professionals have a scary moment of “what ifs” and sweaty palms when the responsibility of our job hits home and leaves us with a charcoal taste in our mouth. I don’t think we get over it, we just have to deal with it.

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Task

The New Nurse: Strategies for Transition into Practice Case-Based Report

Incident Report

The incident is about a busy night shift experienced by Kelley. Kelley has been overwhelmed by work while dealing with both difficulty and needy patients. During the shift, she is stressful and exhausted. While performing her duties she if finding it challenging to handle a patient admitted lasted night for cocaine and alcohol-related condition. She admits another patient and after a few assessments delegates the duty to the third year student nurse. The patient looks normal, until when Kelley asks about scoring from the student nurse. Once she realises the scoring is high, she consults a doctor, and together they suspect the high scoring might be attributed to the patient’s past condition. Later the patient develops sepsis condition, forcing Kelley to seek the collaboration of other nurses. They provide the patient with appropriate treatment, medication and emotional support. However, later the patient ends up being admitted in the ICU. As she rests in her house after ending her night shift, Kelley feels that she has failed to undertake her responsibility, an action that almost caused death to the patient.

Introduction

This paper is based on Kelley’s story on the issues nurses face in their daily work. The story presents a situation where the nurse on night shift feels guilty for not attending to the needy patient appropriately. She feels that her action has led to worsening of the patient’s condition to the extent that she is transferred to ICU. Based on the Kelley’ story, the report will use existing literature to examine applicable nursing and health service principles and practice standards, including, NMBA, ICN code of ethics and NAQHS standards.  Secondly, the report discusses the challenges facing by novice nurses while transitioning to registered nurses. Thirdly, the presentation will explore resilience and its applicability in the nursing guidelines. The paper will conclude by summing up the key issues covered in the presentation.

1. Draw on the literature and critically analyse what has occurred in the case study provided in relation to:

3 applicable Nursing and Midwifery Board AHPRA (NMBA) nursing practice standards

NMBA (2016) presents several standards for practice that registered nurses (RN) likely Kelley must observe while executing their duties. These standards demand that a registered nurse should adhere to RN practice, which involves person-centred and evidence-based elements such as supportive, formative, curative, palliative and preventative (NMBA, 2016).  Based on the case analysis, the applicable NBMA standards are Standard 2, Standard 3 and Standard 4.

Standard 2: Engages in Therapeutic and Professional Relationships

This standard advocate for the RN practice that involves engaging, consulting and delegating duties to other healthcare professionals. Kelley exhibits the applicability of this principle by delegating duties to third-year student nurse to attend to the patient woman. By doing so, Kelley applies element 2.6 of the standard that states that the RN engages in therapeutic and professional relationships if they “use delegation, supervision, coordination, consultation and referrals in professional relationships to achieve improved health outcomes” (NMBA, 2016, p. 4). Kelley further portrays element 2.6 and 2.8 when the patient’s condition worsens, and she seeks the help of other nurses. Element 2.8 states that RN practice should entail participating and leading collaborative practice.

 Standard 3: Maintains the Capability for Practice

This standard holds that as health professionals, RNs are should be accountable end responsible for ensuring their safety and their capacity to practice (NMBA, 2016). Kelley’s application of this standard can be found in the provision of element 3.4 that’s “registered must accept accountability for decisions, actions, behaviours and responsibilities inherent in their role, and for the actions of others too who they have delegated responsibilities” (NMBA, 2016, p. 4). When she goes home, Kelley feels that she was responsible for nearly putting the lady patient to death. Although the student nurse failed to inform Kelley about the patient’s score, Kelley does not lay blame on the student. Nevertheless, Kelley lacked the capacity of the practice to handle the difficult patient who kept following her up and demanding for his drugs. As a professional nurse, Kelley should have engaged the appropriate personnel to attend to the difficult patient man so that he might sleep.

Standard 4: Comprehensively Conducts Assessment

The standard requires RN to comprehensively assess the patient, analyse the patient’s data and information and share the outcomes to advance the best plan of care (NMBA, 2016). Kelley, to a certain degree, applied this standard, for example, she takes the medical history of the patient woman upon admission. Kelley delegates the responsibility of assessing the patient further to a third-year student nurse. Kelley realises that she has not followed up on the patient’s assessment results when it is too late. It is at this point where Kelley can be said to have failed to observe standard 4 wholly. However, Kelley corrects this immediately by consulting a doctor. This illustrates Kelley’s ability to work in partnership with other health care practitioners as advanced by element 4.3. Later Kelley observes that patient condition has worsened as exemplified by difficulty in breathing, high heart rate, low blood pressure, dropping oxygen saturation levels and signs of confusion. In collaboration with the other nurses (application of element 4.3), they conduct comprehensive assessments (application of element 4.2), including ECG,  blood tests, cardiac monitoring and bladder scanning.

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2 principles of the NMBA Code of Conduct

NMBA (2018) has set the code of conduct for nurses to ensure they abide by legal requirements and embrace professional behaviour and conduct in all practice contexts in Australia. In Kelley’s scenario, she applied Principle 2: person-centred practice. This principle advocate for RNs to “provide person-centred, safe and evidence-based practice for improved health outcomes of the patient” (NMBA, 2018, p. 6). Kelley exhibited the principle of person-centred practice by working according to NMBA standards. She documented and reported concerns when she realised the patient condition was getting out of hand. Also, she was working in partnership with other health professionals to ensure the patient’s life was saved. For example, she engaged the doctor when the patient scoring was six, and she again collaborated with other nurses the patient’s situation worsened. Principle 5: Teaching, supervising and assessing is the second principle that applies in Kelley’s night shift experience. This principle call for nurses to “teach and supervise students and other nurses to help in developing the nursing workforce in all areas of practice” (NMBA, 2018, p. 12). Kelley assigns third-year student nurse some duties, and she also goes ahead to state that it is common practice in that word. This shows the application of Element 5.1 of the principle, which states that nurses have a responsibility to develop opportunities for nursing students to learn.

2 elements of the International Council of Nurses (ICN) code of ethics

And 2 ethical principles

Discuss and apply 2 National Safety and Quality Health Service (NSQHS) Standards relevant to the case that now seek to protect the public from similar events

2. Draw on the literature and discuss 3 challenges faced whilst transitioning from novice to registered nurse and with reference to the literature identify strategies to over come such challenges.

Novice nurse is listed in stage one of Benner’s stages of clinical competence (NSW Health, 2016). At this stage, Benner argued that a nurse is a beginner, who lacks experience of all they are expected to perform. As such, while a novice is transitioning to a registered nurse (RN) is likely to face difficult situations. Maria, Stanley, & Mei (2017) assert that the transition comes with both successes and failures, affecting the nurses’ retention, confidence and tenure in the profession. Hezaveh, Rafii, & Seyedfatemi (2016) found that novice nurse while transitioning to registered nurse (RN) face three main challenges: functional disability, communicative problems and managerial problems (p. 217). Hezaveh and colleagues provided various sub-categories for each problem. The functional disability problems are usually lack of primary nursing skills and the need to have specialised and complex skills. The communicative problems range from the challenges while communicating with fellow staff members to communicate with patients. The managerial challenges comprise of decision making, coordination, time management, planning and prioritisation and accountability.

To overcome the transition shock among novice nurses, there is a need to promote success as presented by (Blevins, 2018). Blevins proposed structure and socialisation-based strategies to address transition shock challenges. The structured-based approaches involve creating the programs that aid the absorption of new RNs to the nursing profession and hospital. In Australia, these programs are called transition programs, and they assist in promoting the nurse’s critical thinking skills (AnthonyTuckett, Eley, & Linda, 2017). These programs also offer an environment where nurses can share their emotional and stressing experiences and ask for help on how to address difficult situations. Socialisation-based strategies take place in the clinical units, and they are based on the inputs of the fellow staff, preceptor and unit nurse educator (Blevins, 2018). The three professionals should create an effective socialisation environment to encourage new nurses to seek consultation and feel comfortable. Blevins argues that a novice nurse is comfortable while seeking help from colleagues who are approachable and caring.

3. Define resilience and its application to the nursing profession. Identify strateigies one can employ to foster resilience.

References

AnthonyTuckett, Eley, R., & Linda. (2017). Transition to practice programs: What Australian and New Zealand nursing and midwifery graduates said. A Graduate eCohort Sub-Study. Collegian, 24(2), 101-108.  https://doi.org/10.1016/j.colegn.2015.10.002

Blevins, S. (2018). From Nursing Student to Registered Nurse: The Challenge of Transition. MedSurg Nursing, 27(3), 199-200. https://search.proquest.com/openview/a4912c0df60e8110d879742c35e02650/1?pq-origsite=gscholar&cbl=30764

Hezaveh, M. S., Rafii, F., & Seyedfatemi, N. (2016). Novice Nurses’ Experiences of Unpreparedness at the Beginning of the Work. Global Journal of Health Science, 6(1), 215–222. doi:10.5539/gjhs.v6n1p215

NMBA. (2016). Registered nurses Standards For Practice. Nursing and Midwifery Board of Australia. Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx

NMBA. (2018). Code of conduct for nurses. Melbourne: Nursing and Midwifery Board of Australia. Retrieved from www.nursingmidwiferyboard.gov.au.

NSW Health. (2016). Benner’s Stages of Clinical Competence. NSW: NSW Health.

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