First day in the numbers in critical care.

Yesterday I worked my first shift in the numbers in intensive care as a newly qualified nurse. After a slightly unorthodox supernumerary period including a seven-week long absence due to sickness, as well as starting in the midst of a global pandemic, I had, in total, around six or seven weeks clinical practice before being assessed by a very supportive senior nurse who deemed me capable of looking after critically unwell patients without supervision, which seems to be about average for a lot of ICUs.

Prior to going into the numbers, I had a lot of anxiety about all the things I just didn’t know. I know I can (and I do) ask a LOT of questions, but what about the bits I don’t know that I don’t know?! Will I miss something serious? What if my patient rapidly deteriorates and I freeze up? All of these questions were constantly whirring around my head. Nonetheless, I had to bite the bullet eventually, and I went into work for my first shift working ‘alone’.

Thankfully, I’m not really alone, the education team and senior nurses are incredibly supportive of new nurses into ICU where I work. I was placed working near to very experienced nurses who would be able to help me if I needed it. The patient I was allocated to was a bit of a mixed bag in terms of their nursing requirements with some elements I had previous experience of, and some not.

I set out planning my day which was easier said than done; this patient had a LOT of medications (all IV) and not many free lines, as well as various pumps and drains which needed regular maintenance, and not to mention a very pressing need for regular physical rehabilitation to help clear chest secretions. All in all, my time management was definitely going to be put to the test as I tried to scribble out some kind of rough plan that I was sceptical I would be able to keep anywhere near to.

The day went very fast, and lots of curveballs were thrown my way; a radiographer turned up for an ultrasound I wasn’t expecting, morning physio took much longer than I had anticipated (but was extremely beneficial), stitches popped on the patient’s central line which needed re-suturing. All of these meant I was continually reassessing the tasks that needed doing and rescheduling according to priority. Additionally, due to happenings in the areas surrounding me, I had a much-reduced level of support from colleagues for a lot of the afternoon (through no fault of their own) Needless to say, it felt a bit relentless all day.

At last, the end of the shift came, and I handed over to the nurse for the night shift. I looked back at my shift and weighed up how my first shift had gone. Had I managed to perform every task I had wanted to? No. But I had carried out the essential tasks and any non-essential ones I could manage and handed over the ones I hadn’t been able to do and, I might add, there was no judgement from the night nurse for handing over a couple of jobs.

So, did I manage to do a good job? At the time, it certainly felt like I wasn’t keeping it together, but I talked briefly with the nurse in charge at the end of the shift, and I expressed that I hadn’t done as well as I’d have wanted. However, she highlighted to me that I had managed to deliver all the patient’s essential medical care (including all those pesky IVs!); managed to help them get out of the bed for their longest stint yet with help from the physios; managed to wean down on their O2 support; managed to sort out getting the patient to speak with their family; managed to autonomously deal with issues as they popped up, and managed to ask for help when I wasn’t sure. I realise I said ‘manage’ quite a lot there, and that’s because the penny dropped for me, I had actually managed, not merely scraped through my first shift in the numbers.

Sure, I didn’t do things perfectly, but I left work leaving behind a patient who was a little better physically, mentally and socially at the end of my shift than when I went in at the start. All in all, I’d say that was a success. Bring on day two.

Michael (www.twitter.com/MLJCarter)

An ideal transition…

So, it’s here, you’re doing it, your last placement as a student. I had worried a lot beforehand that I needed to know everything by the end of this placement, and that I would be ‘good enough’, not only for the team, but for my own expectations.

But that first day in blues came around, and amongst the high fives on the way in (after the nearly vomiting with nerves in the car park beforehand!), I remember saying to one of the nurses, who stopped to give me a hug and ask how I was feeling. I confided “I feel a bit like I’m walking around pretending I know exactly what I’m doing”. And her response? Horror? Shock? Escorting me off the ward? No, she just looked at me and said:

“Yeah, what were you expecting? That you’d wake up this morning knowing everything you didn’t know yesterday? Welcome to nursing. I still have days where I don’t know the answers. Every day you’ll learn something new. You know more than you think you do, and you’re doing just fine”.

It is nothing new, and its widely documented that the transition period from student to registered nurse faces NQN’s with many challenges (Duchscher et al. 2009). However confident and ready you feel at the end of your management, that first week in blues feels completely alien. It’s the mix of changes in priorities, schedules and values along with getting to grips with different staff attitudes to NQN’s, combined with not only learning but acquiring the evidence behind new skills and practices (D’Ambra & Andrews, 2008; Rush et al. 2014).

I don’t think I realised during my time as a student just how protected I was. It’s like a tightrope walker, you’re so busy looking ahead, desperate to reach the destination, that you don’t look down and notice the safety net. Until suddenly, you’re in blue, with patients to look after, you’re acutely aware of its absence. But, three months in, I’m starting to realise that instead of looking down, if you look around, you’re not up there alone, there’s a whole team of you, all willing each other on, supporting each other, and keeping each other up.

Although prescribed by the Nursing and Midwifery Council (2018), the level of support each nurse gets during their preceptorship seems to be dependent on where you choose your first job. This would be my advice about first jobs. Obviously, it has to be somewhere you enjoy and in an area you’re interested in. But go where there’s a strong team ethic. Where people work together and where you’ll be supported. Ask what the preceptorship looks like. How much support will you get, who can you go to. We’ve had lots and lots of extra training since qualifying, learning skills relevant to the job. The preceptorship framework includes regular meetings, feedback, encourages regular reflections and a large number of competencies to work through. All of this helps you to feel more secure.

Although many theories exist surrounding the transition period, all would agree higher staff attrition rates occur when the new registrants wellbeing is looked at, alongside the learning of new responsibilities and gaining the increased confidence needed in both learning and performing new skill sets (Duchscher, 2008; Martin & Wilson, 2011). This is further discussed by Rush et al. (2013) who added by starting these discussions during the student period – feelings of shock and abandonment can be decreased.

Cole-King (2018), Peterson et al. (2008) and Wilson & French (2001) have offered many definitions of the term ‘emotional resilience’ – combining the need for, among others, the physical, emotional and psychological resources to cope; to be flexible enough to thrive in the face of adversity. Connor and Davidson (2007) offer characteristics and behaviours of ‘resilience’ – including prioritisation and time management, continuous self-development and pressure management techniques. Wouldn’t it be ideal if we could combine these into a standardised preceptorship programme, beginning during university, to equip new registrants with the ability to not only survive, but thrive in a long career in nursing. With tools such as simulation and scenario exercises, true to practising life as NQN; access to both closed and open forums for NQN’s to openly reflect, share and learn from experiences; an extensive list of available CPD courses relevant to each field, as well as extended access to university VLE’s which, arguably would be most useful at this time, and access to a link tutor contact for those first few weeks, someone who, while impartial to the workplace, has been in the same situation and can perhaps offer support.

I’m really enjoying NQ life, it’s harder than I thought it would be. I’ve laughed, and I’ve cried. Not cried because I wasn’t enjoying it, but some of the things you see, and some of the conversations you have, are, quite simply, overwhelming. But it’s all about support and learning to trust your own knowledge and recognising the areas you need to gain more knowledge on. It’s a new confidence you learn, being able to confidently ask for help without feeling incompetent. Not comparing yourself to others, for their journey is their own, their experiences different, and it takes a variety of people to make a team – this part seems to be all about working out where you fit in. Like a driving test – you’ve passed it, your competent, but now you’ve a car of your own and you need to figure out what kind of driver / nurse you are. 

It’s easy to be negative, especially when under great pressure.  It’s even easier to feel alone when you’re struggling, and to see asking for help as a weakness.  But my time as a student, and in fact more so my time as a newly qualified nurse, has showed me you’re only as strong as the team around you.  

And a great team is full of people who lead in a range of different areas – those who innovate; those who organise and co-ordinate work efforts; those who encourage trust and co-operation; those who litigate; those who act and both inspire and engage others, and those who support, develop and empower people. 

All the research into leadership tells us great patient care comes when nurses feel encouraged and supported by their leaders, and in turn where the work climate is positive and supportive , and where people are given opportunities to participate in decision making, they report higher levels of organisational belonging and job performance increases as a result.

In studies where all nurses are encouraged to be involved in quality improvement -higher levels of empowerment and performance shine through again.  Put simply – where all members of a team are supported and have a voice – they feel involved  and have the emotional capacity to care for others.

Personally, perhaps controversially, I think the capacity to lead is inside everyone, it only shows in different ways.  The temptation at times like these, when everybody in every role within healthcare is stretched and pushed to their limits, is to look for some inspirational celebrity or historical figure, someone who’s achieved greatness despite incredible hardships and measure yourself up against them.

To be inspirational means to make you feel full of hope or encouraged.  And these people are all around us.  It could be your favourite author who uses words like a paintbrush, painting emotions and feelings so real you can reach out and touch them and feel strengthened by their proximity.  Or it could be a friend, who’s going through the most awful time, struggling with the worst kinds of crippling anxiety and consuming depression, but still manages to get up every day and just carry on. It could be a lecturer who invokes such inspiration it’s hard not to be swept along and strive to be as passionate, empathetic and hardworking. And it can be your work colleagues who cheer you up, cheer you on and keep each other going.

In a culture where we’ve grown to measure success by status, perhaps we should instead measure success by innovation, and the effects of such on other people.  By innovation, I’m not exclusively talking about those bringing about huge changes, but also those whose actions and ideas inspire actions in other people.  The carer who sits with a patient with dementia who is unable to communicate their wishes in the way they used to and is afraid – and develops a way to ease this confusion during their shift.  The lecturer who changes and develops modules to suit the learning and perhaps family needs of their students.  The practitioner who helps develop new guidelines and courses to enhance future patient safety.  Work mates who take that 20 seconds to ask “Are you ok? How’s your day going? Let me know if you need anything”

These are all, surely, equally both successful and fundamental to any great team, and furthermore, surely all equal leaders?

Being kind, mindful of the stresses other people may be going through, being respectful and compassionate.  They are none of these passive states.  They each require action, and equally as important – reflection.  Measuring the success of an individual not merely by results, but the growth and development of the actions which preceded it. The end result may be fabulous, but I’m a great believer in celebrating the whole team behind it.  Instead of searching for the negative, which sadly our media seems so intent on –  acknowledge and celebrate all the positives and draw from them. Shout from the rooftops about them. Where negative experiences happen, share them openly and frankly, reflect on them and then keep on moving forwards. 

Don’t Just be a nurse, don’t just be a leader –  be a cheerleader.  Tell the world about all the incredible people who make up your team, who make your day easier.  Tell the world and celebrate the best kind of team – nurses, doctors, midwives, healthcare support workers, porters, domestics, ward clerks and everyone else who, however bleak the outlook, always pull together to look after others.

Kayte (www.twitter.com/kayte83)

Help! I’m a newly qualified nurse starting in the middle of a pandemic.

I’ve just completed my first four weeks as a newly qualified registered nurse. Like many of you, I’ve taken up my first post, working in infectious diseases, in the middle of the global COVID-19 pandemic. I don’t remember the module that covered starting your career during these “unprecedented times”. And I don’t think anything could have prepared us.

In Scotland, to gain NMC registration, most student nurses complete a three-year Bachelor of Science degree. I gained my registration in September 2019 at the end of my third year. But stayed on at university to complete my Honours year, which takes four years in Scotland. I watched my friends who had finished their third years start their nursing careers. Many of my peers completing their Honours year worked part-time as registered nurses while doing so. Due to my workload as RCN Students’ Committee chair, I chose to take my fourth year as a solely academic year.

I didn’t believe I could juggle my studies, RCN responsibilities, and working part-time. I worried all the balls would come crashing down. That I would fail at everything. While I don’t regret my decision, it meant when I started this job, I hadn’t been in a clinical setting since my management placement in August 2019. I was confident in my abilities as a student. I was an “expert” at being a student nurse. But now as a “novice” nurse, I’m constantly worried that I don’t know what I am doing. That I will make a mistake. That this will affect my registration. But most importantly, that it will affect patient care or safety.

I have an incredibly supportive team and preceptor. They have all made me feel so welcome and like no question I have is stupid. I know I can turn to them. But I can’t shake this fear. I think a large part of this is because of when I’ve started. I am the only newly qualified nurse in my ward. Due to the pandemic, our face-to-face induction and preceptorship programmes are not currently running. Also, I work with six nurses who qualified and started working last September when I could have. I see how much they have developed and grown as professionals. I’m so impressed. But it makes me feel so far behind.

The reason I am telling you this is because I know I’m not alone. Last year as RCN Students’ Committee chair, I heard so many stories about newly qualified nurses who needed support: from peers, from colleagues, and from the RCN. The voice of students is loud within the College, but once qualified, newly qualified registrants can feel like they are no longer a priority. Like they don’t’ belong. Like their voices are drowned out by louder members of the College. And that is why RCN Newly Qualified Nurses is so crucial. Because it is yours. We want to hear what you want and need. I want you to know you’re not alone.

This quote from RCN Congress 2018 really resonates with me, “I’ve got your back, you’ve got my ear”. That’s what we want to do at RCN Newly Qualified Nurses. Support and listen. I certainly know I need it.

Lastly, my biggest piece of advice, ironically the one I find the hardest to follow, is to be kind and patient with yourself and take time for you.

I have attached links for our online Newly Qualified Nurses Handbook, and an interview I did with Dr Ruth Oshikanlu, where I discuss the aims of RCN Newly Qualified Nurses (from 19:00) if you want to access them.

We got this!

Craig (@CraigDavidson85)

Welcome to RCN Newly Qualified Nurses

This week, the Royal College of Nursing (RCN) Newly Qualified Nurses launched on Twitter, reaching over 1000 followers in its first 24 hours, demonstrating the need for the voice of newly registered nursing professionals to be heard both within the College and the wider nursing profession. The Twitter site is targeted at all final year nursing students and newly qualified registered nurses, in addition to all those who would like to support these professionals at the early, crucial stage in their career. 

You can follow RCN Newly Qualified Nurses on Twitter at https://twitter.com/RCNNQN

RCN Newly Qualified Nurses aim to provide a voice for newly qualified nurses within the RCN and provide support from six months pre-registration throughout preceptorship. The project is sponsored by the RCN Students’ Committee who states, “The RCN Students’ Committee is thrilled to support RCN Newly Qualified Nurses. It is a very exciting project, shedding light on the unique perspective that the newly registered add to the voice of nursing, providing support and guidance at the beginning of their nursing journey. We know it will make a huge difference.”

The RCN Newly Qualified Nurse Network was initially launched in November 2018, by former RCN Students’ Committee Chair and student member of RCN Council, Charlotte Jakab-Hall. The network began with a closed Facebook group for newly qualified RCN members https://www.facebook.com/groups/RCNNQN/

Subsequently, former RCN Students’ Committee Chair, Craig Davidson, and former student member of the Trade Union Committee, Clare Manley, developed a project plan, leading to the creation of “RCN Newly Qualified Nurses”. This project is now lead by Clare Manley and the current student member of the Professional Nursing Committee, Kendal Moran. Joining Clare and Kendal to curate the RCN Newly Qualified Nurses Twitter account are a team of final year nursing students and newly qualified nurses. This team includes Craig Davidson, RCN Students’ Committee Chair, Jessica Sainsbury, RCN Students’ Committee members, Dawn Marr and Lynsey McLaughlin, RCN Student Information Officer of the Year 2019, Aimie Morgan, runner up for RCN Wales’ student nurse of the year, Kayte Powell, Michael Carter, Daniel Branch, Beth Phillips and Abby Martin. We are currently recruiting more curators, making sure we equally represent all four UK nations, fields of nursing, and promote equality, diversity and inclusion among our curators.

RCN Newly Qualified Nurses will provide content and support, showcasing and signposting newly qualified nurses to all the RCN can offer as both a Trade Union and Professional College. Additionally, we will promote the newly qualified registered nurse’ voice to shape the RCN and wider nursing agenda. We aim to hold regular Tweetchats, and we are excited to announce there will be an upcoming RCN Newly Qualified Nurses podcast hosted by Clare Manley and Craig Davidson. Most importantly, we want to hear from you, the newly or soon to be newly qualified registered nurse and those who support us to find out what you want from us. We welcome you to join us on our exciting new journey supporting this often underrepresented group.

RCN Newly Qualified Nurses.