Tuesday, April 24, 2007

what's the point of policies?

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!

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Tuesday, April 03, 2007

violins and nursing errors

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.

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