The following is a guest post by Vanessa Katsoolis.
If I ever come across a nursing student in their final year of their Degree that is willing to be honest about how they feel the first thing they will say is that they feel they don’t know enough, that they are scared that they are going to graduate, get their scrubs, put them on and walk into their first day on the floor and not actually know what to do next.
I can remember feeling like this. I can remember being on placement in my final year, especially my final semester where I had an ED placement and looking around at the RNs who all seemed to know where to go, who to talk to, what to do and when to do it and feeling so incapable and so far from that level and almost wishing I could study for another year, another two! I felt like a fraud, that I had somehow gotten this far only because I had flown under the radar, that I hadn’t been ‘found out’ for being the inexperienced, unprepared nearly-nurse that I felt I was.
This feeling that I was a fraud followed me into my first day as an RN. I still felt that I had slipped through the cracks and that my scrubs and my kicks and my ID were a disguise, that I had no business wearing them.
I wish someone had saved me from going through all of that. I wish that I had been more honest with how I was feeling and that someone was able to tell me what I would eventually learn for myself: That I wasn’t a fraud and that I was in fact as prepared as I possibly could have been, that I wasn’t pretending to be a nurse, that I was b ecoming a nurse.
So I am going to try and write you something that I think would have made a difference to how I perceived the world that existed beyond the double doors of the hospital entrance and hopefully quieten the accusations of self doubt that you are carrying, even if it’s just a little bit.
My first year was spent in the Medical Assessment Unit (MAU) at a large tertiary hospital in QLD. MAU is a relatively new type of unit which works alongside the ED. MAU takes everything apart from stroke codes and paeds. Our bread and butter was cardiac mainly, undifferentiated abdo pain, stuff like that and as the name of the unit suggests, people would come to us to be assessed and for the initial investigation into their issue commence (ECGs, bloods, investigation into their medical history etc etc)
The grad program for MAU is known to be tough because of the high turnover of patients, the acuity, the thoroughness in the investigations and the variety of symptoms and conditions that you might be juggling in a single shift. Nurse to patient ratio was 1:4 and of 4 patients one might have had a NSTEMI, one might be a DKA, the other might be sepsis and another might be abdo pain. I can tell you that at the end of my first day, which was largely observational, after seeing RNs reading ECGs and saying things like ‘hmmm, looks like he’s got a left bundle branch block’ or looking up pathology results and say ‘That troponin came back positive, we’ll need to start the ACS pathway’ and listening to them handover to other wards using what sounded like another language of medical terminology and numbers that meant nothing to me, I thought that I wouldn’t last the week. I felt very small and very scared and suddenly didn’t think I wanted to be a nurse anymore.
Within a few weeks though, I would shake my head at myself for ever feeling that way and would finally understand how the healthcare machine worked and how to move within it and contribute to it.
How did this happen? How did I go from feeling like a fraud to feeling like a nurse? I hope my explaination of how things work and my tips and ‘nurse-hacks’ make it easier for you in the last weeks of your Degree and the first weeks of your practice.
So like I said, the healthcare system is a well oiled and well established machine. The Degrees to train the clinicians who eventually end up working within the healthcare system are in themselves well developed and it’s important for you to trust the process. I promise that you won’t be thrown into the deep end and watched to see if you sink or swim. Your entire first year will be similar to the stages of getting your Driver’s licence.
As a learner you will most likely have several shifts of what is called ‘supernumerary’ (being paired with a more experienced RN) and you will move through each shift together to give you time to settle in to the environment you’ve found yourself in and to become orientated to where things are, how this machine works, how that gadget turns on, how that line of communication works etc. Getting used to administering medications will also be slowly introduced to you by certain restrictions on who you can check meds with, getting things co-signed, having a facilitator check in on you regularly to make sure you understand the procedures and answer any questions you have and offer general support.
For us we were not allowed to check out S8’s (schedule 8 medications such as morphine etc) with another newly graduated RN in our first year out. This took some of the pressure off knowing that those types of medications would be checked by someone with more experience. Your hospital and unit will have its own way of slowly introducing you to the environment, the practice, the medication administration or invasive procedures but however they do it in your clinical hood, they will have a way to ease you into it all.
Once you develop more confidence and experience in your clinical setting you will be allowed to do more and more independently, similar to being on your Restricted/Ps licence, but there will always be a chain of command and different resources at your disposal any time you have a query or just want to double, triple check something before you go ahead with it and don’t feel shy or feel like ‘a pain in the neck’ for utilising these resources even when it’s busy. You will earn WAY more street cred for becoming known as a safe new nurse than you will if you just want to try and avoid ‘bothering anyone’ and get on with it by yourself. I will add a list of tips at the end of all of this but one of them will include these words: No one likes a cowboy.
The other RNs, your team leaders, your facilitators KNOW you’re new, they understand that you will be feeling like a deer in the headlights, they will know that every year between Jan and March there is an influx of newly graduated RNs and other clinicians that need a bit of extra support just like they did in their own first few months and the machine caters to those new RNs, those new doctors, those new pharmacists, those new physiotherapists……. Pretty soon you will understand that the life and health outcome of this person does not and never will rest solely on your shoulders, that it is a collective effort made up of you as the primary nurse, your nursing team leader, the Doctors and more senior Doctors, the pharmacists, the allied health team members, the radiographers…… Clinical decisions for each patient are come to by a collective effort and utilises the information gathered from a range of varied sources during open discussions with many different members of the healthcare team.
Your voice, your observations and your input as the primary nurse will be a valuable contribution, but it will also only be one contribution out of many and this is why that gang of people behind those hospital doors are referred to as a TEAM. So be encouraged, the responsibility of someone else’s health, especially in an acute setting like ED is big, but it is shared.
Remember when you were first learning to Drive? You were just this terrified little bean behind the wheel wondering how you would ever survive even 5kms on the open road without killing someone when you didn’t even know how to move off smoothly in first gear and do the clutch thing and the indicator thing and the hill starts with the handbrake thing?….And yet I bet you do all of that on autopilot now, you don’t even think about the handbrake or when to put the indicator on because it’s just second nature. Nursing is SO much like this. At first you will feel overwhelmed simply because you don’t know how it all WORKS and won’t be used to doing A, B and C.
I WISH you knew how quickly you would be Doctoriving through each shift without consciously thinking about all those things, how it will become second nature simply because you will be immersed in the environment every day.
So, below is an example of a question I was asked recently that is not an uncommon one:
I am currently finishing my final placement in critical care and I have a job starting there right after qualifying. Although I’m having second thoughts, it’s so hard there, I feel like I know nothing… so just wondering what type of experience is more beneficial for preparing for ED.., would you suggest having experience on a medical ward, or similar?
The short answer is: No. Aim for exactly what you want straight off the bat. Start in ED if you see yourself as an ED nurse and you are fortunate enough to get a graduate program in ED or an acute setting such as a Medical Assessment Unit.
The long answer is: When student RNs have a goal of working in an area that they deem to be more intense such as ICU or ED etc, they often query whether they should apply for something ‘less intense’ and then work their way up once they have more experience. I encourage you to let this idea go and aim directly for the clinical area you want to work in and see yourself working in STRAIGHT FROM THE OUTSET.
The reason being that as a learning nurse in say, ED you will have the grace and support of the system, those around you, facilitators etc to BE a learner in that environment without the expectation that you should know more or already know how the whole medical world works and you will be eased into THAT environment at a pace that is safe and reasonable for you at your stage of learning, which is the beginning. Every different kind of nursing (Neuro, palliative, renal, ED, Gen med, ICU) has its own way of doing things, its own culture, its own pace, and its own method of learning it all. If you see yourself as an ED nurse and want to begin your career there then if you have the opportunity to: START there.
It is far better to do it this way than to have a year or two in Gen Med, then enter into ED a few years later and into that whole new culture/new world without the support that new RNs get. Of course not all RNs get to begin their career in the area they ultimately want to end up in. If this is the case for you then work hard and diligently in your unit, learn as much as possible, undertake additional courses or partake in extra learning at home that builds upon the knowledge you will need once you ultimately DO get a position in the clinical environment you are aiming for and be patient during the journey to your final destination. No experience is wasted experience.
Another common statement: It’s so hard there (in ED) I am having second thoughts.
Yes it seems daunting because you have been shadowing and learning from RNs on clinical placements that only get paired with student RNs because they are EXPERIENCED. They get paired with students because they have become so used to their clinical environment and so competent that they can now be in a position where they can impart wisdom and provide guidance to an apprentice. And so you have been watching them work, with all their years of experience under their belt saying to yourself ‘I am NOT ready for this! They know way more than me, if I get thrown into this environment in my first year as an RN i’ll sink!’
Because you are imagining that you will somehow have to perform at their level and know what they know from the very outset. But this is not the case, that’s not how it works. You will be given responsibilities in bite sized chunks as you can handle it and in a pace that is applicable for you and as they deem you to be ready for so, like I said; if you see yourself as a particular kind of nurse and have a particular field of nursing in mind then AIM FOR IT AND START THERE if you have the opportunity to so that you can be the apprentice of that environment.
GENERAL REASSURANCES FOR COMMON CONCERNS
- MEDICATIONS: You won’t be expected to know every medication and the way every medication works and the indications for them etc etc straight off the bat. There is no way of remembering every medication there ever was anyway (that’s our pharmacists job!) What you WILL find is that there are certain medications that become the ‘locals’ for whatever clinical setting you find yourself in, a certain handful of them that are typically administered and you’ll just get to know them inside and out, how to prepare them, how to give them, when not to give them etc, etc simply because you will be working with them every day. Respiratory has their common meds, Gastro has their common meds and ED has their common meds. When you find a medication charted that you haven’t heard of before, do what the rest of us do EVERY DAY and look it up or ask the pharmacist or the Doctor that prescribed it. RNs and Doctors seek advice from our pharmacists or look up the administration guidelines nearly every shift, we check with our peers, we ask each other ‘have you EVER heard of this rogue med before?’ That’s how you learn. Everyone does it. Doctor’s do it. Everyone. Totally normal.
- ‘SCARY’ STUFF LIKE CANNULATING AND TAKING BLOOD AND PUTTING CATHETERS IN AND ALL THAT JAZZ: If you work in an acute setting like ED you will learn neat clinical skills like how to collect blood samples, how to insert an intravenous cannula, how to put in catheters. Again,you won’t be expected to know how to do this straight off the bat, it’s called a ‘competency’ for a reason. You will be trained in how to do it, once you complete your little learning package you will be supervised and guided when doing it for real and you will be given the space to practice with support (my precious friends in MAU offered up their veins to me for practice when I was still learning, bless their souls.) Only then, once deemed COMPETENT you will be allowed to cannulate and take bloods from every man and his dog but the only way to learn at the end of the day is to DO. (Watch one, do one, teach one as they say.)
You will never be put in a situation where you will be asked to do something you have never done before without support and guidance. A Doctor might not know you are a grad nurse and ask you to ‘grab a Troponin off Mr Dude’ one day before you know how to take bloods. In that case you say ‘sweet! I’ll do that now’ and then go to your Team Leader and say ‘Help!’ and you’ll go through it together. For that matter: if you are ever asked to do a procedure or administer a medication that you aren’t confident or comfortable doing then say so and either offer to help another nurse in their tasks so they can do it with you or let your team leader know you are not yet competent so another nurse can take care of it and the training you need be organised for you to complete at a later stage.
- BECOMING PART OF AN ESTABLISHED TEAM: As a new nurse you will join a team of RNs and Doctors and allied health team members that have most likely worked together for some time and all seem ‘down’ with each other. This can initially make you feel a bit shy and you will definitely feel like the new kid at school for a little while. For this I say: Give it time.
Prove yourself as being a hard worker, a SAFE nurse who isn’t afraid to ask questions and get your practice checked, and be humble and respectful. Mutual respect and trust in one another is e ssential i n a clinical setting. We depend on one another every day, we carry our hits and misses as a team, we essentially carry the lives of other people in our hands together. So when a new team member is added, especially when they are a newly graduated nurse, the existing team members will need to suss you out a little bit and to get to know you. The best, most wonderful thing you can do in your initial weeks on the floor is to show you are SAFE.
By safe I mean: Asking lots of questions, double checking how to do something or what that word means, where this goes, how this thing works…. Basically showing that you KNOW you are new and you KNOW you need help and support. Once your fellow team members can see you aren’t going to go rogue cowboy on them they will be able to relax and slowly you will start to become one of the team.
Never feel like the initial feeling of being ‘the new kid on the block’ is a negative reflection on you whatsoever. Remember that these people, especially in the ED setting, have shared some of the most confronting and life defining moments of their life together and in time you too will become part of those experiences where you look across the bed at the other nurse or another Doctor and know that you will never be able to ever explain to someone else what it was like to face what you two or three or 10 just experienced together. These people will soon become some of the most important people in your life, but give it time.
P.S: Night shifts are often when a bit of bonding takes place. People are more open on night shifts, their guard isn’t up as much, it’s a more ‘honest’ environment and i’ve found some of my most beautiful and eye opening conversations with my colleagues have been have in the depths of a night shift. A couple of those under your belt and you will become ‘one of them’ soon enough.
- JOIN: ‘The nurse path’ group on FB. I LOVE this page. It’s a community of 86,000+ RNs/clinicians and the couple who run it (both ED RNs based in Australia) are always publishing VALUABLE information, education, articles, support, encouragement, opening the floor to feedback and stories, allowing people to ask questions and have hunDoctoreds of people comment their advice and tips……and as this couple are ED RNs, the content is usually applicable for ED. https://www.facebook.com/theNursePath/
- UTILISE YOUR ALLIED HEALTH HOMIES: Every clinical setting will have a resident Pharmacist, physiotherapist, occupational therapist, social worker and in a more acute setting you will also have Mental health, Aged care specialists, Security team members etc etc. Get to know their names get to know how they like their coffee and use their wealth of knowledge. I have found that they actually really appreciate being asked for information and most feel pretty stoked that you have asked for their advice and input and therefore some of my best learning moments have been talking with our pharmacist to seek insight into a medication or talking to our Physio to get tips on patient mobilisation or getting security to give me tips on de-escalating a situation etc etc. It won’t just be you utilising them either. You will soon notice how often Doctors and RNs approach them for ideas and information, our poor pharmacists especially (I used to have our old pharmacists email and phone number on speed dial) Again, we are a team.
- LANYARD CARDS: The first year as a nurse I had a selection of good quality, informative lanyard cards on my lanyard which I had with me every shift. These lanyard cards had everything from blood gas reference ranges and interpretation, common Drug name prefixes, Urinalysis interpretation…. A Doctor in MAU where I did my first year has a company called Lanyard pearls. It is the place I got all my cards and I couldn’t recommend them enough. https://www.lanyardpearls.com
They are developing more cards all the time, the ones they already have (so many) are EXCELLENT and you can even design your own if you don’t find quite what you are looking for. They are $3 each, they do free shipping worldwide for orders over AUD$30 and I can’t express enough how much these cards helped me in my first year.
THINGS I’VE LEARNED ALONG THE WAY
THE HOSPITAL IS YOUR PLACE OF WORK, BUT FOR OTHERS IT CAN BE A REALLY SCARY PLACE TO FIND THEMSELVES IN:
You will already be so used to the clinical environment that it feels like a second home, but next time you are in a busy hospital unit, especially ED, take a look around and imagine it from the perspective of someone that is there for the first time. Listen to all the beeping, the alarms, the noise, the other patients yelling out or crying or in pain…. There isn’t too much we can do to change the nature of the environment but something I do for every single patient is orientate them to where they are and to give reassurance. I am in the habit of making it part of my initial introduction to myself and my building of rapport to just explain a few key things like:
I will explain to them that they will hear a lot of alarms, that they may even hear the equipment they are hooked up to start to make noises and alarm. Now to be in hospital and already be scared and then hear the machine they’re connected to start alarming can be really terrifying because they may not know what it means, they may not know that it’s just the stupid battery needing to be plugged in or that it’s just the monitor reminding the nurse to add the patient details in. So I explain what these alarms might mean. Eg: “The machine used to administer the fluids or a medication is really sensitive, it will alarm if you accidentally bend your arm and the flow stops or it will alarm when the infusion is nearly finished, it will alarm when the battery is getting low and it will alarm if someone looks at it in the wrong way so if you hear this start to beep at you that’s the kind of thing it will be beeping about, but here is your call bell, if you do hear beeping or alarms that make you feel uneasy, use the bell and i’ll come and explain”
I know this might sound novel but I have had a few people burst into tears when i’ve said something like that and confess that when their monitoring started to alarm they thought it was something to do with their heart, that the alarm meant that they were suddenly really, really sick. How awful to think about someone lying there with such scary thoughts running through their head when it might just have been that I forgot to plug the cord into the wall and the battery was running low!
Unless you can see that the patient is well used to a clinical environment then take the time to explain a few things to save them from being any more scared than they have.
*EXPLAIN HOW THINGS WORK/WHAT IS HAPPENING TO YOUR PATIENT:
In ED we do several routine tests for every single person that comes through no matter what. Some people can get the impression that may be sicker than they thought or that their loved one is sicker than they thought when they see us conducting some of these routine tests especially if it uses equipment they are unfamiliar with. An ECG is one example of a routine investigation that can be perceived as really scary by someone who hasn’t had one done before. Anything that involves lots of tubes or leads or monitoring, even a BP cuff or the Sa02 probe can feel alien to the patient and their loved ones, so I always just run off a little spiel about what i’m doing and how the equipment works and what they can expect to it to feel like. Again, I have had quite a few patients or their family members thank me for explaining things like this, especially how the ECG worked, some even admitted that when they saw all those leads they were scared they were going to be electrocuted! Or that it meant there was something really wrong with their heart! Poor little lambs!!
Medications should be given with an explanation also:
The saline flush we give before and after every IV medication? WE know it’s just salty water to flush the line, you know what some patients might see? Clear, mysterious liquid being mainlined into them with no idea what it is or what it will do to them. Explain what it is!
Always explain what you are giving and putting into your patient and if they have any questions or if they understand why. ESPECIALLY with the elderly. Elderly people by come from a time where you would never question ‘The white coats’. They came from an era where questioning the Doctor or any clinical staff was considered to be almost disrespectful, so when you come to them with a little cup of medications that look different to the medications they take every day at home because our stock is simply a different brand to theirs, many will simply take the medications and then lie there wondering if they have just taken a cup full of the wrong heart or BP medication and yet never say a word. I always mention to any patient being given one of their routine medications from our own stock that ours might look a little different to theirs at home because they are a different brand but that it is exactly the same dose and exactly the same ingredients and then ask them if they need them clarified/each one identified for them.
*IF A MEDICAL EMERGENCY CODE OCCURS:
If I am not directly involved with the code I reassure all the other patients within earshot/view of the code. It hasn’t been uncommon for me to discover that the patient was thinking: If THAT person over there is so sick that a big alarm is going off and there are people running and a crash cart being wheeled in to save them and here I AM in the same room in ED then does that mean I am that sick too? Is a big alarm going to go off for me?I’ve literally answered questions like this for patients who are within earshot of a code. Providing reassurance and explaining what they might have seen can make a huge difference to their experience and memory of being in the hospital.
After I have introduced myself and orientated the patient to their surroundings I always make them PROMISE me they will let me know when they are in pain and be honest about how much pain they are in. Too many people (especially the elderly) will white-knuckle their way through terrible pain because they ‘didn’t want to bother you’.
I always make a pact with my patients and sometimes even make them shake on it that they will tell me when they are in pain. If I suspect they could be a ‘white-knuckler’ I will say something like “If I discover you have been suffering in pain and didn’t tell me, I will go home today feeling absolutely awful so you promise me ok? Caring for you and looking after you is the only reason I am here today and if I find out you have been suffering I will feel like I failed you”. That usually does the trick haha and it’s important because pain, especially extreme, relentless pain can reduce someone’s ability to cope with the situation. Effective management of pain for your patient should always be among your top priorities, especially in the ED.
You can drastically change someone’s experience of their presentation to hospital by assuring them that they are allowed to ask questions, they are allowed to seek reassurance and an explanation of what is happening and an idea of what will happen to them next. Just because a person does not ask or does not verbalise it, it doesn’t mean they aren’t absolutely terrified and require reassurance. Fear is another thing that a lot of people just white-knuckle their way through but so much fear can be removed from the experience by explaining what you are doing and why, updating them on the plan, using layman’s terms in your explanations and never assuming that just because they aren’t saying so, that they aren’t afraid. Always try to imagine what this world of ours must look like and sound like to someone new to it.
One of the reasons a lot of people become healthcare professionals is because they care about other people, they want to make a difference, they want to help, they want to save lives. What could be more horrifying for someone with a heart for others than the idea that as a human, mistakes can and will happen, mistakes that could hurt someone, mistakes that affect others. Tip number 5 will be about avoiding mistakes but this tip is about damage control if you, as a human being who isn’t perfect and will make a mistake at some stage despite the fact you desperately never want to, eventually makes a mistake.
If you make a mistake tell whoever you need to tell IMMEDIATELY.
- Every single time.
- No matter what.
- No exceptions.
If it is an ‘insignificant’ error then it will be noted down, the Doctor or whoever applicable will be made aware and may make a change to the provision of care to counter it, may implement an intervention to correct it or perhaps it will be so minor that you will simply be shown a better and more savvy way to do that procedure or mix up that med or mobilise patients in the future. It’s a small error, you’ve reported it, you’ve proven to be accountable and can be trusted to report and own up to mistakes and all is well.
If it is a big error than it is VITAL to report it straight away. The sooner it is reported the sooner interventions can start to reduce the impact it has on your patient or your colleagues. The b est chance you and your team have on minimising the impact that a mistake has is to report it as soon as possible. You will be hardpressed to find a Nurse that has never made a mistake or had a really scary near-miss. I have and my patient was ok because I reported it straight away and the situation was managed. Yep, I felt miserable for a while afterwards, felt pretty sheepish and i’ve certainly never forgotten it but it made me even more careful moving forward and made me realise just how vital our safety nets are….
Every medication! No exceptions! CHECK THE 6 RIGHTS OF MEDICATION ADMINISTRATION! Right Drug, Right Dose, Right route, Right patient, Right time and their Right to refuse/Reactions (Patient’s right to refuse the med/checking possible REACTIONS/ALLERGIES)
It’s been drilled into you for a reason. Those 6 rights are your safety net, your seatbelt. Medication errors can and eventually WILL happen if you don’t check each of them habitually every time you dispense medications. In fact, every time one of my student nurse’s has begun to make an error with medications while I have been supervising them, it has been because they weren’t going through the 6 rights in their head and they have, for example, prepared a medication that was a PO med when it should have been IV or dispensed a med at 08:00 that was actually charted for 20:00. I will sometimes allow the student to go ahead and prepare or dispense the medications into the medication cup without saying anything and JUST before we go to leave the medication room I will point it. While it seems a bit mean and yes, they always feel pretty sheepish and embarrassed about the error, I do this because 1. It really shows why we have those 6 rights and 2. The cringey feeling of being shown that they had made an error can be really impacting and the feeling hopefully stays with them to show them that most medication errors are ‘stupid’ mistakes that using the 6 rights would have saved them from. Don’t want to make a medication error? 6 rights my friend. Every time. No exceptions.
TALK TO YOUR PATIENT:
Your patient is often the best source of information and are another one of our safety nets. If I am giving a patient’s regular medications to them I always tell them what I am giving and ask them ‘Is that what you usually have? Does that sound right to you?’ There have been a few times that it has turned out that one of my patients actually had a recent dose change or recently ceased a medication that was charted and by asking the patient for their input and organising for our pharmacist to review, a small error was avoided.
No matter what it is, no matter how busy it is, if it gets into your patient via a needle or a cannula then get the medication and your dose checked by another nurse. We have a policy to do this but even if your hospital doesn’t: Get it checked. 99.9% of the time you would have drawn up the exact right thing at the perfect dose. But we take these precautions to act as a safety net in the unlikely event that we haven’t.
Handover used to be one of the most daunting parts of the shift for me. I used to feel quite vulnerable, like my practice was really put under the spotlight in front of this other nurse who I was trying to give handover to. I actually used to dread it all shift! Also, now that I have had experience I KNOW how essential it is to give a good, thorough and concise handover, how important this communication is and how much it can impact the ongoing care of the patient. I spent weeks as a new nurse trying to come up with techniques and methods in giving a good quality handover and after trying several different things I finally found something that worked for me so I’ll share my method with you and maybe it will help you too.
SBAR. I don’t know what your health care system guidelines are regarding handover but here in QLD Health we do handover in what is called an SBAR format. (Situation, Background, Assessment, Recommendation)
When handing over in any situation, whether it be to the new nurse coming on shift, handing over to the nurse on the ward the patient is going to or even handing over the situation to your other team members during an emergency code, we use the SBAR format.
- Situation: Identify name, gender age and presenting or current complaint/issue.
- Background: Background of presenting complaint (eg: time onset of symptoms, any interventions done immediately prior to arriving at hospital) as well as wider medical history (Chronic issues such as COPD, Diabetes, History of MI etc etc)
- Assessment: What we have observed so far and results to any investigations that we already have (Whether obs such as BP, HR, Temp are all normal. What blood tests or other tests we have already done and if results are already back, what they show and then pain score etc etc.)
- Recommend: Basically, what happens next (Urine sample needed, patient is for chest xr-ay or CT head, patient is for physio review or mental health review, Neuro obs every hour, pt is to remain on telemetry…. This kind of thing)
So my method:
Now, whatever method your health care system recommends you provide handover in, you are initially going to wonder how you are ever going to:
A) Keep up with the plan of 4+ patients as each plan develops and remember every test result as they come back, remember whether it was Mr Cool with the history of COPD or whether it was Mr Dude and what the ongoing management plan for all these different people are and:
B) How you are going to communicate each plan in a thorough yet concise way to whomever you are handing over to at the end of your shift.
I recommend you do this:
When a patient presents to hospital and is assessed by the Doctor, the Doctor will write an admission note. As SBAR is our method of handover the Doctors here write this admission note in SBAR format.
Now, EVERYTHING we know about the patient thus far will be on that admission note. The Doctor will have written what the patient presented with, what the background of this particular complaint is, what the medical history of this patient is, any medications they take, any allergies they have, what tests have already been done and the results of those tests, what they think the diagnosis is or a few things they t hink it could be, then what they want to happen next such as any blood work, any particular observations and how often, who they plan on consulting with, any investigations they have ordered or any team they want to review this patient.
MAKE A COPY OF THIS ADMISSION NOTE. If your unit does notes on the computer then print the Doctors admission note off the computer. If it was handwritten, photocopy it.
Add the patient number to the top if it’s not already there as you will need that if you are looking up any test results or handing over to another ward. Also write the name of the treating Doctor at the top too so you know who to liaise with about this patient.
As the shift goes on and as results come back and new tests or new plans are made for the patient simply add it by hand to that note.
Once you have the admission notes for your patients in your pocket you will feel a peace of mind knowing that the initial details and the progressing plan for each of them is on that piece of paper and can be referred to any time you need it, so that if someone comes to you and says ‘Hey do you know if Mr Dude is on home oxygen’ or ‘What was Mr Dudes Blood gas results?’ then you just refer to that admission note and the notes you have subsequently added to it and you can confidently give the information.
I still print off the admission note and add information to it for every patient on every shift. It helps me keep up to date with what is happening with each patient during the shift and helps me to manage my time and prioritise care and put things in order. Please remember though to put these notes and anything else with the patient’s personal details into the shredder bin before you leave every shift, never carry anything containing patient information with you out of your clinical setting.
This little spiel of mine should by no means be taken as an exhaustive guide nor does it encompass nearly everything I wish you knew nor do I claim to know it all. I know only of and remember the apprehension I first felt in my first days, weeks, months of my nursing career, I know only that I am still at the very beginning of a life-long learning experience and, just like I rely on the support of those further along the road that I am, you may gain encouragement from people like myself who have walked the path you are walking now. Something I want to leave you with though, perhaps even more than anything I have written up until now is this:
Nursing has become one of the most beautiful, wonderful, defining parts of my life. I love my job, I believe it is one of the most incredible professions in the world and my heart is to encourage others and try to make the transition into this amazing world more easy.
Every nurse that ever was and ever will be will have to go through an initial baptism of fire as you embark on your career. There are ways to minimise the heat of this by getting advice and reading articles and getting encouragement but there is no way of avoiding it altogether and for that I am actually glad because that initial year as a nurse? It changes you. The challenges and the way you overcome each one, The fear and the way you face up to it every day and start to conquer it…. It would be a shame for any new nurse to be robbed of such a defining experience by having it come t oo easy.
You are about to become part of a world that you will never be able to explain to any one who doesn’t share it. At first you will wish you could explain it, that your
friends, your family could get a peek at what goes on behind those doors because some of your most remarkable human experiences will happen there and you will want to talk about it…..
But soon you will also realise that it is impossible to explain it and you will become ok with that. You will start to value how special it is to be a part of a world that is secret to all but those who move within it, that the bond you have with the people you share it with is different to any other kind of relationship you’ve ever had or will have with anyone other than those people, that even if you used a million words you could never explain to someone what it is like to stand in a room and watch 8 other RNs and Doctors move together as if one and put every ounce of focus and physical strength into saving the life of someone they have just met, the name they might not even know yet. You will realise that a million words would be insufficient to explain how the experience of holding the hand of a person whose light is starting to fade from their eyes has changed you to your core and how your job makes you appreciate the fragility of life, sometimes even how fleeting it is.
You will soon realise that a single day behind those hospital doors can be unforgettably intense and beautiful or become a more confronting, more tragic human experience than what some will experience in a lifetime. You will go through things and see things and recover from things with your colleagues that binds you together for life, the same way all of the most life altering experiences when shared with another binds people, it’s just that for you these experiences will become almost common, a part of just another day at work.
You will stop answering the questions from friends or family about how your day was with anything more than ‘Good’ or ‘Ok’ or ‘Hard’ because you realise that some of the things that have become normal for you are too confronting for those outside those doors to hear about and because of that you will value and desperately NEED the friendships you make with those other men and women who pull their scrubs on and lace up their kicks and go to work in that beautiful chaos with you every day because they will know…. They will know.
You are not about to start a job as a nurse, you are about to become a nurse. There is nothing I have said in the thousands of words I have just written to prepare you for it, you just have to dive in darling.
I’ll see you there.
Love Sister Vanessa
“This is it, don’t get scared now.” -Kevin McAllister, Home Alone