Steep learning curve - see below

The above diagram represents what I feel has been my learning curve during my first week on UMAU. Patients are referred for their GP or through A&E with all sorts of medical problems and conditions that need further investigation and management and there are many, many differing protocols to learn about and apply, such as insulin sliding scales, managing hypos, confused patients etc, septic screening, SOB, chest pain etc etc. My first day on the unit was the first time I administered all my IVs with no supervision, it took me some time to learn about how to administer certain antibiotics and this was quite stressful as I am always on a time constraint. The sister went through my patients in the morning after the docs had done the ward round and we identified who needed what..bloods to be taken, cannulas to be inserted, Trop tests to be done at a certain time and a hundred other concurrent things to do. I was very overwhelmed as this was all quite different from the previous ward. I got through the day somehow and went home and read up on things I didn't understand.It is difficult to enjoy stress but I keep my sights on gaining more confidence with experience. Whenever you first come across something new you learn from it and next time you know what you are doing..for example managing a patient with a peg feed, that was quite scary at first but I think I would manage it ok now. That's why things are stressful at present, every day I go in wondering what I'm going to have to learn on the hoof, and do it fast and right. But I have also learnt to follow my instinct if I suspect a patient needs more specialist input and the REFER, REFER, REFER to nurse specialists and specialist therapies. Anyway, they gave us another brown envelope last week saying that in Nov the winter escalation ward would open and we would all have to re-interview for our jobs on UMAU. I didn't much like the sound of that so did what I was planning to do and applied to the post in oncology. Thankfully I had taken the time to visit the ward, speak with the sister and read up like a mad thing on coherent answers to likely interview questions, it paid off as they offered me the job. I anticipate that the mode and ethos of care delivery is totally different in oncology, not so frenetic with more time building relationships with patients and their families. I will hand my notice in this week and work out my notice for the month. Then start my THIRD job since qualifying.

What do you mean 'the ward is closing in 2 weeks?'

OMG They told me a nursing career can take many unexpected twists and turns but I never imagined things would take a turn so soon in my career. I have been on MAU for 4 months now and last week we were called into the office and given a brown envelope each and told that the ward will close in 2 (yes, 2)weeks time...can you believe it. So all the staff, including band 6 and 7 as well as CSWs are all being redeployed to other wards and areas of their choosing if those jobs are available. However if too many people are going for too few jobs in a particular place then they will have to go to interview and hope for the best. I had opted to go to oncology but I will have to apply and hopefully be invited to interview. I never imagined I would be moving away from MAU so soon. I will let you know how it goes. I will visit the oncology ward on Tuesday to speak to the sister there and try and butter her up! then, once I know more about what they are looking for I will come home and apply for the position. Wish me luck X

Some shifts are one long hard slog

Positve encouragement from the web and colleagues is great and a really useful tool to keep your own enthusiasm and stamina going, but make no mistake, being an entry level staff nurse on a very busy NHS ward is extremely hard work that requires physical and mental focus and stamina. I don't spring out of bed at 5am every day I'm working and bounce in to work. Mostly it is a matter of gearing myself up to the task ahead...13hr shift of non stop effort and responsibility. The secret that I've found that keeps me going is to understand and accept that I'm working within a complex and therefore flawed system which cannot be fixed. I have to just do my best in the circumstances and deliver the best service I can. If I follow policy as closely as possible it affords me some protection from omitting aspects of care or just making mistakes, such as drug errors. Sometimes when we are under-staffed the shift is one long race to the finish. I am often so concerned with completing the paper work fully that it takes away from my time with patients. Ironic isn't it?

First appraisal meeting of my career

Ok, a week ago I met with one of the sisters I'd been working alongside for my yearly appraisal. This is where you get feedback on your performance and have the opportunity to discuss any areas for development and agree on a plan of action for the coming year. I really enjoyed my appraisal, the feedback I got was positive and we discussed strategies for developing my delegating skills when working with clinical support workers. It was decided that I enroll on a course to develop my knowledge further; 'assessment and management of the critically sick patient' was what I felt I needed most at this time. I'm waiting for the start date to be published so I can apply for it. Also I fancy the 'career development workshop', which should allow me to formulate some direction and game plan for my career. The sister told me that all the staff nurses on the ward are encouraged to take up a role of link nurses and asked which field I am most interested in, I looked at the list of options such as tissue viability or cardiac and I found myself strongly drawn to palliative care. I do love this field of nursing because I find it to be one of the most fulfilling and rewarding service nursing can offer. So I am now the palliative link nurse which means I need to enroll on palliative courses given by the Specialist Nurses. I have taken the opportunity to introduce myself to one of them and told her of my interest, so will keep an eye out for these courses to come up. Another objective I have set myself is to send off my application to the RCN to be trained in being an RCN steward. This means I will learn to support colleagues, who are RCN members, through difficult work related disputes and disciplinaries. I am very passionate about this role as I feel the NHS has the capacity to serious mistreat staff who need advise on employment law and NHS policy to strengthen their position. I am very keen to learn to offer this service to colleagues, so I have given myself till the end of July to complete the rather lengthy form and send it off.

Improving on knowledge as well as time management

It is not abnormal to start your nursing career and first job feeling uncertain of your knowledge and abilities. My primary concern in this new post was to learn the routine of the ward and learn about referring to others in the multidisciplinary team as well as escalating my patients to the medical teams when necessary. Learning these things has taken some weeks and now I find that I can just about manage my shift. I am improving my handover s but coming unstuck when others ask specific questions relating to treatment, such as medication. I live in dread of the question..'so, why is this patient on....?'. Currently it's still OK for me not to know the answer to such things as blood chemistry values etc but I want to know these things. So my current plan of action is to read up about specific topics on my days off. I choose one or two areas I need knowledge in and focus on reading a bit in the morning and again in the afternoon to gain more insight and understanding. This morning I read up about Warfarin and INR values and its antidote vitamin K. By placing this pharmaceutical within its historical perspective I feel I understand it well. My message here is that as new nurses our knowledge bases will vary, this does not make one better than the other. The trick is to identify where your particular weakness is and work hard to improve upon it. It is useless to have a nurse who super hot on the sciences but cannot communicate with sensitivity with the patient and their concerned family and conversely nursing isn't all about tea and sympathy to the detriment of sound medical knowledge. There lies the balance of art and science that is nursing.

Adding to my knowledge little by little

I feel at this stage that I am familiarizing myself quite well with the routine and rhythm of a typical shift on my ward. Of course I still need to iron out certain sticking areas during the day, such as the afternoon hour or two while the doctors are reviewing my patients and haven't updated their plan for that patient. The routine is becoming clearer but what I need to learn more about now are the reason and rationale for the investigations and plans of treatment those patients are undergoing. This means expanding my knowledge about medical conditions, such as heart failure, COPD or chest infection etc. So during my 3 days off this week I am dipping into the above book expanding my understanding of all sorts of things. Now I have about 45 mins before sleep time so I will find something of interest to read...

Think before you pick up the phone

Part of developing my skills I need to refer a patient who needs more specialist care to either doctors or critical outreach. This needs to be done on the phone BUT under no circumstances should a nurse just pick up the phone and hope she can recall information about the patient off the top of her head. What is more professional and efficient is to have the nursing and medical notes in front of you so that whatever questions they may ask, such as..'what is the par score?' or 'what is the latest medical plan for this patient?' you can reply with accurate up to date info that is detail rich with all the numbers at hand. This means your patient will get the timely help they need. It was a doctor who gave me this advise yesterday, she said she had been caught out a few times not having been prepared before making a call and being told to call back when she had the relevant information. I must try to remember this good advice.

planning my shift

These few long days I've just done have been like going on a mining expedition, drilling down into the hows and wherefors of the practicalities of my role. As I drill into the layers of information I need to learn the more displaced matter is flying around, making things, temporarily, more confusing. One of the trickier and more confusing things has been discharging patients, mainly because there are so many things to remember to do and arrange. Lots of forward thinking..where are they going to? Will their residential home accept their current condition? How will they get in? Do they need a care package? Have I informed the next of kin? Has their EDN been completed and has pharmacy been informed of the take out drugs they need? etc etc etc...All this is very time consuming, and I'm already rushed off my feet as it is..oh and don't forget to book transport at the right time for the patient. My morning routine is coming together but there are still things to add on such as beginning to think about and plan all of the above for those due to be discharged. If I note these patients down then I can plan my afternoon activities better. Discharge is time consuming and this will allow me to plan it into my day.

I did it! My first long day in charge of my own bay

Wow, my feet ache like crazy but I'm not mentally tired at all, in fact I feel mentally invigorated....but my feet kill. I was in charge today (with the sister keeping an eye on me). When a patient needed PRN analgesia or had a climbing par score it was me that was in charge of it. My time management skills were fine and I achieved everything I needed to in the time allocated and handed over to the night staff. I noticed my hand over was so much more informative now that I'm solely in charge. Doctors discussed patients with me and all info went through me so I wasn't having to play catch up. Now I just need to organize myself better in the afternoons so that I am on top of discharges and transfers, I have documented the current plan from the ward round and I am on top of the documentation. I am on again thursday, will try and do this then.

It's kind of like learning to dance

And of course dancing (in nursing) is seldom a solo activity. I am making it my business to be on first name terms with the team, I ask them who they are, which team they're in (if they are doctors...and this is quite complicated, still working on that one), what their name is and tell them my name. Once I've done this their expression opens up and we begin to relate to each other like human beings, which is great for my patient as I get clear information. Today I made a point of introducing myself to the pharmacist and requested that next week, when I am in charge of my 7 patients on my own, when he changes the timing of medications to tell me personally if he can. He was fine about it and as we stood there he said 'Oh, this is a good time to do some teaching' and took me through a prescription chart explaining all the amendments to look for next week. Saying hi to staff and introducing yourself open up avenues of communication that may never come about. Today I found myself tentatively dancing quite a few steps - OK, they weren't all joined up and many of them were missing - but it's more steps than I've strung together so far on a shift...AND I'm meeting some wonderful people, both patients as well as staff. What is there not to like??

The path of learning

Every shift I complete teaches me a little further along the road of learning my job on my ward. Today I had my final assessment of drug administration and I passed, which means I can administer meds on my own without being countersigned. Now of course the responsibility of possible mistakes is palpable, so asking when in doubt is essential. When I got home tonight I read up about Acute Coronory Syndrome and Troponin testing as I have heard these discussed among staff and wanted to know more about it. In fact I find that it's much better and more empowering to look things up that I'm not sure about straight away rather than letting it drag. This applies to meds too - I have a little address book that I write meds info in. Overall I feel a little more prepared for my shift tomorrow.

embrace feeling out of your depth

I remember when I went to visit the ward before I attended my interview. Sometimes a throw away remark by a member of staff can contain so much information, clues to what the job may be like for staff. The sister said to me 'it's sink or swim here, you either survive or...'. And now I know what she means. These 2 weeks contain my supernumerary shift with other nurses. These nurses are a great support and they constantly reassure me that even when the 2 weeks is up I will hardly have scratched the surface of my experience. However today, for the first time in my blue dress, I was standing in the throng of nurses, doctors, physios, OTs and other staff, taking a handover and trying to organize management of my patients...and ....I was totally out of my depth. As though I was at the bottom of a deep ocean of murky, inky water with the blurred glimmer of sky and sun far above me. When I made a foolish mistake when I was handing over, the whole collection of people heard, when I tried to back peddle and appear in charge, the whole collection of people heard...in fact my lack of knowledge and experience was there for all to see. It was not a very comfortable place to be. Can you relate? My conclusion is to embrace being prepared to act and speak, knowing all can hear you, and not be too self-conscious. Be prepared to speak up and take risks, which of course includes getting it wrong publicly. At which point be prepared to chuckle at yourself and not beat yourself up too much.

How will I tackle my next shift

I am still supernumerary for one more week and then it's long days and in charge of 7 patients. It is important to set learning objectives for each day otherwise I'll be swamped with the myriad of things that need to be done each shift. These are the things I'm currently not achieving effectively: Delegating to CSWs/other staff. Keeping up with all the changes that happen for a patient on each shift (new plans from doctors, whether patients have been taken to investigations. Getting drug round done within 2 hours..I know. Filling in ALL the nursing notes, assessments, hourly checks, body maps, daily weights etc etc etc etc that need to be done. Finding any time to answer the phone on the ward. Basically keeping up with everything. My last shift was Friday and I've had the weekend off. I have spent so much time reflecting on how to approach the shift on Monday and to juggle everything as well as stay abreast of all the changes, additions and developments that are continually happening to patients...and then be prepared for discharges and transfers, not to mention all the referrals that need to be done. Now some other more experienced staff seam to do this and make it look easy and that's where I want to be soon. So, tomorrow I will ask to take 3 patients and do everything for them. That way I can learn how to do the above mentioned things in a controlled fashion, rather than try to take 7 patients on at once. Will reflect on this on Tuesday.

Last day of induction programme - and a word about confidence

Do you see the above picture as a sunset or a dawn...well, in this instance it represents the end of studenthood and the dawning of a new era in my (and perhaps your) career - and life. Two weeks in and many presentations later I am now on a two week short days stint, working with another member of staff on all the shifts. I have had so much information thrown at me over the last 2 weeks, now it is time to try and assimilate it and, slowly shift by shift, apply it as circumstances require. By this I mean...what to do if a patient's vital signs dramatically, or gradually change. How to respond to a cardiac arrest. What to do when a patient passes away on the ward and many other challenges to meet and conquer. Or perhaps, how to handle an agressive patient or a wandering patient with dementia who is convinced he needs to leave the ward, find the nearest bus stop and go home...even though he hasn't lived at his home address for several years. Yes, nursing is a long list of paperwork and policies to abide by - remember if it isn't written down it hasn't happened. Now, confidence. I love the saying 'fake it 'till you make it' and I think it applies perfectly to my situation. Now I DON'T mean fake my knowledge resulting in unsafe practice, that would never do. I do mean, however, portraying a self possessed and confident manner even when unsure of what to do. One thing I've noticed I have which I think robs me of confidence when I hear it; my voice gets very high pitched and faint when I am nervous which I don't think inspires much confidence. So for the next 4 shifts this week I will concentrate on finding my confidence, meaning even when I feel my nerves and uncertainty welling up inside me I will take a moment to choose to respond to the situation in a calm and measured way, most importantly check that my voice remains grounded. If this lady can do it, so can I.

Two week induction is an essential part of transition

The transition from student nurse to staff nurse is greatly eased by my two week induction programme into the trust. Part of this are 5 supernumerary shifts where I slowly familiarize myself with the lay out and routine of the ward I am working. I have been given many forms to fill in within this time which mainly outline the essential knowledge I need such as admitting patients, discharging patients, transferring patients etc. In this time I have also been inducted into the computer system of the place so that I can access the staff intranet and patient management, emails etc. During this time I have very gradually realized that I am in fact being supported and not just left to my own devices to either sink or swim. The staff on the ward are always approachable and on hand to patiently explain things. Induction is also a chance to familiarize yourself with hospital policies, such as drug administration or blood transfusion. Remember abiding by the policies is the only things able to protect you from making lethal mistakes. They are there to not only protect patient but practitioners also. A very interesting session was about delegation which outlined the demarcation of registered nurses' responsibility when delegating to clinical support workers. Delegating responsibly, intelligently and politely is a skill to be improved upon.

Challenges, challenges

Ok I have established that we are all extremely nervous and it has helped to discover that others are as nervous as I am, however, today - the third day of induction - I have been inundated with various forms, tick lists, policies to read, worksheet for medication test to name but a few. We sat from 9 - 5 just ploughing through all these good things, thankfully led by very efficient and prepared nurses. Now the work really starts because tonight I have to sit and read/sort through everything. Advice: buy whatever folders/dividers etc you need so that your papers are put together like with like. I don't want to be a nurse who can't recall what info was given during induction. I want to action all 3 (lol) lists that I compiled today and get ready for my learning. Tomorrow I start my first supernumery shift, I don't know what to expect or how dedicated/interested my preceptor will be but I will go in with the right tick lists to give myself a structured opportunity to build on my learning. what have I learnt today? That I am responsible for my own success in this job. If loads of papers and info is chucked at me then it is my duty to organize it, familiarize myself with it and complete what is necessary. Another thing I've learnt is some people in that room seamed to understand what was being asked of us so much better than me, they naturally followed every instruction, whereas I really struggled to keep up some of the time. I have different strengths and weaknesses to others' and I must not beat myself up about it.

I'm Looking Forward To Starting My Job But I Feel So Nervous...Is This Normal?

I am finished with my nurse training. My last day as a student was April 14th 2013 and I have been offered a my first position as Staff Nurse on MAU at my local hospital. After 5 weeks home catching up with friends and family, doing a bit of spring cleaning and pottering in the garden with my dogs the time for my induction programme is upon me. Suddenly I am hit with the realization that I now have to prepare myself to take up that position and give it my best. First my induction, then my supernumery shifts on my ward, followed by working through my preceptorship programme. Once that is achieved then it will be a steady development into that professional person I aspire to be. I wonder what experiences and opportunities will come my way to stretch and challenge me. Well, dear new graduate, do you wonder what knowledge, understanding and realizations you will acquire over the next 12-24 months that will allow you to embody a professional and competent nurse? One who comprehends the legal and ethical requirement of her/him and one who is truly capable and reliable? I bet you have observed such nurses, bustling about going about their business. Generally they are clear-eyed, physically capable women and men who appear to know what they are doing and why and, dare I say it, enjoy it. Firstly and most importantly if you feel scared and anxious about starting that hard-won first position you really MUST understand that you are not the only one. I am on my Trust induction days now (day 2)and all my newly qualified friends echo this sentiment of trepidation. 'Will I be able to deliver what is expected of me?', 'Will they think I'm not up to the job?' and 'What if I make a serious drug error or other serious mistake?'. We all think this and I've been told by more experienced nurses as well as midwives that they would be concerned if I was not feeling like this and was 'overconfident'. So give yourself a break...I know it's much easier to say than to do. Believe me I feel exactly the same but it has been a comfort to realize that even experienced nurses (like some on my induction programme) who are moving from a comfortable old job to a new one in a new trust also feel anxious and nervous. Even though they have many years of track record behind them they all say that they feel out of their comfort zone and that they are going into a strange and unknown situation. In short you are not the only one who feel uncertain of themselves and their skills and knowledge, apparently you should feel reassured that you are taking your new duties and responsibilities seriously enough to feel that you will need to dig into your reserves and to undertake a transformation from newbie to competent, safe practitioner. I hope it will be an adventure.