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Unfair Nursing Situations at the Bedside

Updated on September 1, 2014

Have We Come a Long Way or Do We Have Lessons to Learn?

When considering the unfair situation I described and nursing’s past, I would say we have come a long way. Many advances have been incorporated into nursing practice since the times of Florence Nightingale, although she certainly set the tone for the future of nursing. Chinn and Kramer (2011) stated that “Nightingale advocated that nursing was much more than knowledge of facts and techniques” (p. 27).

Vast advances have been made in knowledge development with one example being evidence-based practice. Evidence-based nursing practice is a group of words that is synonymous with best practice in my area. Becoming most known in the 1990s, evidence-based nursing practice started in medical texts, and incorporated research into nursing practice to ensure high quality care (Chinn & Kramer, 2011).

3. Reflecting on the described experience, how would you reframe this experience to be described as a ‘fair’ approach today?

Reflecting on the experience, I believe there are many processes that could be improved. First, I would focus on scheduling a mix of experienced and inexperienced staff together. When census is low, dates for standby should be recognized, but not be the ultimate decision maker. If the nurses left to work have been with the institution for a short amount of time, a standby nurse could be utilized to orient and resource a new nurse to a more acute patient or a situation not present during their orientation.

Mentoring could also be utilized for those who have completed orientation. This would assist the new nurse to get incorporated into the unit’s culture and gain acceptance. The mentoring relationship can help ease frustration by providing a resource for questions and concerns. It can also help foster teamwork between coworkers, allowing them to educate each other, rather than making a list and demanding disciplinary action from supervisors.

Lastly, staff rounding could be utilized by the leadership team. Setting time aside to make staff feel important and discussion of issues can empower staff and assist in creating a teamwork atmosphere. When I held a position as a Clinical Educator, I met with my new staff and their mentors monthly. We were able to work through potential barriers and foster friendships that have lasted a decade so far.

An Unfair Situation in CCU

I encountered an unfair situation that involves the Critical Care Unit I work in and new staff that have completed orientation. It is customary in the Critical Care Unit (CCU) for new hires to be assigned low acuity patients for the first few weeks following completion of their orientation, while experienced nurses take the high acuity patients. The CCU has time periods that census is incredibly low, however, and staff are put on standby, where they can be called in for admissions. When this occurs, nurses are placed on standby according the date of the last standby shift, sometimes leaving an inadequate mix of experienced staff without a resource person. Numerous times the new nurses have been confronted by the oncoming shift with a list of duties that were not completed according to the unit’s standards. The lists would even include items such as emptying garbage cans or using a particular color label on tubing. This not only leaves potential to jeopardize patient safety, but it leaves the new hired nurses frustrated with their coworkers and unsatisfied with their jobs.

One particular nurse had 23 years experience exclusively in critical care. She had completed 6 weeks of orientation, was released to work on her own, experienced this situation several times, and a coworker brought the situation to the attention of the director. The nurse was then reprimanded and placed in the Intermediate Care Unit, where she eventually resigned from a short time after.

Lack Aesthetic Knowing?

The nurse described did try to fit with the culture and use her coworkers as resources. I work nights and we all perform tasks as a team. Unfortunately, she worked full-time at another hospital with differing policies in place and only worked at my hospital once a week. She felt like she was starting over every week and the oncoming shift always found something to criticize her about. I felt some of the other staff were threatened by her years of experience at a larger teaching hospital and cast their judgment early, always looking for something that was done differently. The night staff where I work always attempt to form informal mentoring relationships, as a formal program is not place. A formal mentoring program may have prevented the situation from escalating.

The experienced nurse could have returned to orientation. This is a practice that has since become standard. Because I work in a small community hospital, not all situations are available during an employee’s initial orientation. The Director now will put newer staff with a preceptor during a shift that has special procedures planned or other situations. The length of orientation is standard for the new graduate nurse, but it is individualized for the experienced new hires. Providing these occasional orientation shifts has helped with the development of new staff.

I don’t believe all nonexperienced nurses lack aesthetic knowing. Many nurses have had previous careers in various settings from banking, elementary education, paramedic, to nurse assistant. I think we draw from these past experiences. According to Chinn and Kramer (2011), “the nurse’s sense of meaning in the situation is reflected in the action taken” (p.10). Where one new graduate nurse may freeze during a code, I don’t think that a new nurse with a paramedic background would respond quite the same way.

What is Aesthetic Knowing?
Awareness of the immediate situation, seated in immediate practical action; including awareness of the patient and their circumstances as uniquely individual, and of the combined wholeness of the situation. (Aesthetic in this sense is used to mean "relating to the here and now"
Chinn and Kramer (2011)

Make the Situation Fair

Reflecting on the experience, I believe there are many processes that could be improved. First, I would focus on scheduling a mix of experienced and inexperienced staff together. When census is low, dates for standby should be recognized, but not be the ultimate decision maker. If the nurses left to work have been with the institution for a short amount of time, a standby nurse could be utilized to orient and resource a new nurse to a more acute patient or a situation not present during their orientation.

Mentoring could also be utilized for those who have completed orientation. This would assist the new nurse to get incorporated into the unit’s culture and gain acceptance. The mentoring relationship can help ease frustration by providing a resource for questions and concerns. It can also help foster teamwork between coworkers, allowing them to educate each other, rather than making a list and demanding disciplinary action from supervisors.

Lastly, staff rounding could be utilized by the leadership team. Setting time aside to make staff feel important and discussion of issues can empower staff and assist in creating a teamwork atmosphere. When I held a position as a Clinical Educator, I met with my new staff and their mentors monthly. We were able to work through potential barriers and foster friendships that have lasted a decade so far.

What Do Think?

Has Nursing Come a Long Way or Does Nursing Have Lessons to Learn?

See results

Be Socially Responsible!

A socially responsible nurse would require a multitude of attributes to meet the demands of this century and beyond. First, a leader, educator, and social change agent must be an active listener. They must be able to make others feel important and worthy of being lead, taught, or changed. Next, they must possess assertiveness and knowledge so that they can be heard, understood, and believed. Finally, they must be able to approach others in a manner that is non-judgmental, objective, and supportive. They must know when use an attribute such as these more strongly with some, and weaker with others. According to the American Nurses Association (ANA) (2009), “emotional intelligence is an important skill set and attitude measurement for administrators” (p. 8). These attributes would ensure the success of a leader, educator, and social change agent when confronting difficult situations.

Positive Experiences Shape Our Future

As a new nurse, I felt I had an excellent 12 week orientation that was structured to cover particular skills and situations every week. I was assigned only one preceptor and worked exclusively with her with the exception of a few shifts. My preceptor had several years experience on the unit, had participated in a preceptor training course, and advocated for me even after orientation was complete. She was my mentor for the first year of my employment before she left the unit to further her career.

Following her resignation, I became a preceptor myself. I strived to be the patient, knowledgeable, protocol oriented, nonthreatening individual that I had been exposed to during orientation. Management heard and saw how prepared my oreintees were, and began involving me when any changes were being considered with orientation. I mentored several of the nurses I trained and developed relationships that still stand today despite changing institutions. When I was asked to be the Clinical Educator of that unit, in charge of all staff orientation and training after only 2 years as a nurse, I had to accept and put into action my vision for everyone’s orientation to match that of my own.

A new nurse’s initial orientation to her first nursing job is a pivotal time in her career. It can influence future attitudes and build the foundation for job satisfaction. For these reasons, leaders should advocate for proper orientation in terms of length, structure, and preceptor selection. Eddy (2010) states that just one of many elements included in a preceptor program should be support from the organization with adjustments in workload and support form nurses in staff development. Preceptors are leaders themselves and should complete education to ensure an understanding of policies and the importance of their role. Preceptor selection is crucial as they should also possess an open line of communication with management for situations such as overtime and feedback for evaluations.

My positive experience at the beginning of my career helped mold me from a scared new graduate nurse into a professional. It made me realize the importance of every interaction we have in the healthcare profession. Chinn and Kramer (2011) provide that praxis is an individual and an interactive process. I have also witnessed the unfair situations such as described by Shalanda and Hercedes, but I know that I will continue to embrace my vision that was developed during those first 12 weeks.

References

American Nurses Association (2009). Nursing Administration: Scope and standards of practice. Silver Spring, Maryland: Nursesbooks.org

Chinn, P., & Kramer, M. (2011). Integrated theory and knowledge development in nursing (8th Ed.). Mosby Elsevier: St. Louis, Missouri.

Eddy, S. (2010). Lessons learned from formal preceptorship programs. Creative Nursing, 16(1), 198-199. doi: 10.1891/1078-4535.16.4.198


Be a Leader!

In the future, leaders must possess the highest skill level of problem solving achievable. They must be able to adapt and remain flexible so that they may approach any issue, and be able to come to a solution or improvement. Educators in the future must stay advanced with technology. There continue to be advances and opportunities in regards to healthcare education on the internet. In addition, simulation exercises with computer devices such as SimMan are available. Practice based nurses in the future must continue to challenge and develop their critical thinking skills. As diseases mutate, pharmacological choices increase, and the trauma patient becomes more complex, nurses providing patient care must maintain their knowledge and think fast!

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