Quality Practice Environments : Quality Care

gwenith, BSN, RN · Feb 22, 2004

Alberta is not a "for profit health care" province... yet. But boy does King Ralph want to see it become one. He is all for deregulation and letting someone else foot the bill. In the ten years he has been premier of Alberta, he has slashed government budgets to the bone, forced departments to change the definition of their clientele in order to exclude more people from services and deregulated all utilities. These measures were supposed to save us all money, but really have resulted in the opposite. Electricity and natural gas are now costing individuals and businesses alike as much as double what it would in a regulated system. Auto insurance is often as much as triple or quadruple what other provinces pay. Highway maintenance has been privatized and the carnage due to poor road conditions is unbelievable. Education is being starved, with elementary school classes containing up to forty children. And then there's health care. He loves Alberta's annual prestigious first place in MacLean's magazine's Health Care Review, and is bending over backwards to bring as many high-profile programs (such as the vaunted under-construction Alberta Heart Institute) into play as possible, but won't pay the bills these things create. I could go on for days. I won't. I already have a headache!

Hmmm sounds depressingly familiar - are you sure all our premiers and Prime Ministers across the world are not in secret collusion with each other to bring down health care and line their own pockets????

moia · Feb 22, 2004

Well, God bless your naivete.

That there book learning is almost amusing if I didn't remember that I too was filled with good intentions when I graduated.

Be realistic, you will be a brand new grad so your first job is going to be on a medsurg or geriatric floor. You are going to be assigned 6-8 patients. You will never stop running to do the bare minimum. I guarantee you won't have time to worry about your environment because you will be way to terrified and run off your feet.As a brand new grad you have no experience so expect that any ideas you have will be ignored.

A Bachelors degree probably means that you have very little meaningful clinical time so your skills will be severely limited.Despite this you will be expected to perform these skills immediantly. Your first year of nursing will be hard and scary.

Once you get one year under your belt and start to feel a little confident your floor will be chronically understaffed so you will soon be doing resource or charge. In your second year you will be responsible for everything on your floor and you will have 4 patients on top of that. You will be exhausted and will have no interest in tackling the critical care program which is your only hope.

You will stagger through night courses and clinicals again and by your third year you will have completed the critical care program only to find out you need ACLS and five other courses.

Your fourth year will go by and by your fifth you will be a pro on your floor and will finally have collected all the requirements to finally go to critical care where you will start at the bottom again and discover that despite the fact you have one patient they are covered in so much technology you are terrified again.

You will be in your sixth year of nursing before you catch your breath and remember that quality thing...then you will look around and see 5 agency nurses and 3 fulltime and realize that all you are doing is treading water trying to keep them alive for your 12 hour shift.

Then you will blow out your back while turning a 300 pound heart patient with the help of a PSA who forgot she was supposed to be helping because that was the moment her drugs kicked in.

Nursing is basic survival of the fittest now, we don't have time for philosophy .

I am sure if you decided to carry on and get your Masters and became management you could have alot of meetings to talk about it but frontline nurses are in a guerilla war just trying to keep their patients alive.

I am still deeply resentful that my nursing teachers portrayed nursing as if we were all important innovative members. Ofcourse only later did I discover that the teachers hadn't been nurses for many years and in 2 cases I had teachers who had never nursed at all.

Ask your teachers when were they last on a medsurg floor. Respect the teacher who came from nursing and later chose teaching. Beware the teacher who went straight to the classroom.

I respect your interest but you may need to put that aside until you can catch your breath.

Remember that your union is your friend when it gets really bad.

Consider going to the US before you nurse in canada.

vislandnurse · Feb 22, 2004

Hmmm...this is all sounding very depressing...Tell me what keeps you in this career? Tell me what is good in nursing? There must be some benefits, otherwise you would not still be doing what you are doing while facing so many challenges. Put aside my interest in quality practice environments and quality care? Nope, can't do it. If we don't hope for change and have a vision, how will things ever get any better? I refuse to give up on the belief that things will get better, as from the posts it seems as though things cannot get worse. Not sure what others have experienced with Bachelors degree education, but I am in clinical two days per week (definitely not all book learning), my instructors have all nursed on the floor (most recently)- some still nursing on holiday breaks - practical education in classes such as professional growth, ethics and nursing research. Call me naieve and idealistic, but that belief in ability to change is at the core of who I am as a person - am I the only one?

JMP · Feb 22, 2004

No Vislandnurse, you are not the only one. I am disheartned that the previous poster has left such a negative impression. If you have been learning about nursing history ( and I am sure you have) you will know that the negative- "horizontal violence" is commonplace in SOME workplaces...... the reality is that you bring your own ideas and ethics to the workplace and working in an unethical and depressed unit leads to feelings like the previous poster has stated.

Her reality is not your reality and certainly it is not my reality------ we need new nurses who are willing to change the enviroment and push the outer limits-- and just to let you know----I value those who look to inspire and lead by example.

Yours in nursing leadership- JMP

vislandnurse · Feb 22, 2004

No Vislandnurse, you are not the only one. I am disheartned that the previous poster has left such a negative impression. If you have been learning about nursing history ( and I am sure you have) you will know that the negative- "horizontal violence" is commonplace in SOME workplaces...... the reality is that you bring your own ideas and ethics to the workplace and working in an unethical and depressed unit leads to feelings like the previous poster has stated.
Her reality is not your reality and certainly it is not my reality------ we need new nurses who are willing to change the enviroment and push the outer limits-- and just to let you know----I value those who look to inspire and lead by example.
Yours in nursing leadership- JMP

JMP...THANK YOU! HOPE...

fergus51 · Feb 22, 2004

I love nursing and would never do anything else. There are certainly days it is challenging to provide the level of care I want to, but I have found it is usually possible where I work. This is not an accident. Since my first horrific job, I have been very careful of where I have chosen to work.

vislandnurse · Feb 23, 2004

Thanks fergus51!!!

I KNEW that it is possible to be happy and love nursing.

:)

moia · Feb 23, 2004

You may have thought to ask Fergus about that first horrifying job and read carefully what Fergus was telling you before you congratulated yourself. And no it isn't depressing at all. It is just what it is. I am amused that some are so vocal about the nursing shortage and WSIB and are immediantly cheerful with their "I wuv nursing buttons " on when anyone actually tries to tell a new grad what the real world is actually going to be on a busy big hospital medsurg floor.

Why I continue to nurse is because it MUST be done. The thought of abandoning these people and leaving them under even worse conditions is just not an option.

I may be seeing a different side because I work in a giant inner city teaching hospital.I work with the desperately critically ill.

I thrive on the challenge of keeping desperately injured/ill people alive. What keeps me going is the moment when I realize that my patient has done the seeming impossible and changed course and their survival is possible. That feeling of accomplishment can't be met doing anything else.I do not look for my environment to provide me with quality, I create quality through the work I do. I can create quality with every action.

What I have done in my career is demanded respect at all times from everyone. My environment is beyond my control but the quality of nursing care is ALWAYS my job. It is the only thing in nursing that the nurse controls. You can never accept less from yourself . The satisfaction and joy comes from knowing (without anyone else telling you) you have done your best.

Sometimes you will have to reshape your idea of quality care when you have 8 patients. You may have to decide that quality care for these patients is making sure they are bathed and their meals are eaten and they got their meds that day. Sometimes quality is ensuring basic rights. In my situation quality is different once again. You will have to make some hard choices but if you make a commitment to provide the basics of survival and dignity for your patient then you won't go wrong.

There was nothing inherently negative in my description of nursing, what I did demonstrate is that nursing is hard and challenging and demands everything from you.

I have never had the perfect nursing job where challenge and hard work doesn't exist.

A new grad who is ambitious which I presumed you were is going to have to be ready to work hard and overcome challenge to finally come to place where you will have enough respect from your peers and your management to begin to suggest change.

You can't expect to graduate and get your first job and then promptly question your environment and begin to express dissatisfaction with it immediantly. You will have no credibility.

Everyone was quick to label a very realistic first 5 years of nursing as negative,depressing and harsh. That is silly, your first 5 years are all uphill hard work. Expect it to challenge you and make you nuts but take satisfaction in the fact that as tired as you are going to be you are going to have victories that make it all worth it.

Nursing isn't a job that everyone can do and I sincerely wish that people would stop labelling my job as negative, it's hard. If you think hard work and hard circumstances are "negative" then I can only see that for you the job will be a bad choice.

We need to be open and realistic. the fact is most nurses who graduate are going to get their first job in a big hospital that is reflecting the nursing shortage and making do with less full time nurses and using alot of agency. That is the reality here in Ontario. I have no idea if the rest of Canada is experiencing a nursing winfall and each nurse has 3 patients and good breaks all I can tell you is about life in a big metropolitan teaching hospital where we don't have enough critical care nurses to look after our trauma patients and do all the open hearts we schedule. Everyday we cancel surgeries or close to trauma because we don't have the nurses to cover the beds and most nurses are doubled with vented patients. Every day we can't transfer patients out of ICU because there aren't enough nurses on the wards to take them.

Thats fact and you can label it harsh or depressing or whatever, that is nursing . Expect your job to be hard and you won't be disappointed.

vislandnurse · Feb 23, 2004

In your original post you did not qualify the type or area of nursing with any details, you only did this in your last post. So you describe nursing in a "giant metropolitan teaching hospital caring for the desperately critically ill". I live in a small 'rural' community, therefore my reality may never ever be what you experience. Therein lies the danger of describing nursing from such a vantage point, as there are other experiences out there. I have made the decision to pursue nursing as a career choice because I thought that perhaps I might be able to make some small differences in peoples lives...and yes, I understand that it is going to be extremely hard work. I am beginning to examine environments now, so that perhaps I will be able to avoid what fergus51 describes as the first horrific job. The RNABC provides a pamphlet for new grads to help them examine potential employment environments and then make appropriate choices (quit laughing :)) I understand that things can be pretty terrible out there, otherwise there would not be so much discussion about quality practice environments. I don't expect to move into my first job and dictate change. I imagine that I will likely be happy to 'cope', but I have to hope. I guess as a nursing student, I have to maintain some kind of optimism and idealism otherwise I would never get through this. I found this last post of yours encouraging actually, because you describe what keeps you going, why you don't give up despite the harsh realities you face everyday. You are obviously very passionate about the work that you do, and are likely excellent at it.

So another question from a student: Do you think that if government and employers are faced with new grads and others evaluating their options for employment, and then taking the jobs that hold the best promise for them to be able to practice according to the standards they may have to acknowledge that the situation must change? You mentioned earlier that I should nurse in the US before nursing in Canada. Have you done this? Are the practice environments that different there?

moia · Feb 24, 2004

I am always a little suspect of the "I want to affect other peoples lives" quote but I am a miserable cynic. You really can't survive on that. You must not be hoping for patients to ever express this change. You really need to decide what does nursing do for you? What part of nursing gets you revved? Stick with that and don't worry about making a difference, "making a difference" is a cliche. Get a rush out of doing a really kick ass job and enjoy that.

In all honesty it is rare to ever see or hear that you made a personal difference so you must be your own cheerleader. You may only see your patient for moments or in my case my patients rarely have any memory of the ICU at all.

Also remember that patients just don't stay in hospital that long anymore.

I went straight to the US after grad..I went to a tiny southern hospital and I worked everywhere, ER, our tiny 2 bed ICU, medsurg and in the end I was House Supervisor.

That tiny hospital paid me to get my critical care diploma and paid for acls and all my intubation/ventilation training. When I was ready I moved to cardiothoracic intensive care in a big city hospital..this was 1 year after grad. I was trained to the teeth in open heart and one year later returned to Canada fully trained and experienced.

My US experience was hard every day, challenging and exhilirating. I was ready for anything. In the USA I was treated like a professional and given incredible respect from my peers and my patients, even the doctors weren't too bad.

I returned to canada and to Toronto where I was shocked to find out how incredibly far behind we were in technology and as a profession. I witnessed behaviour from my peers that wouldn't have been tolerated for a moment in my workplaces in the us. The basic attitude toward employers is antagonistic.

My US hospital cherished us and couldn't do enough..an example..if we had an arrest on the unit the house manager arrived with pharmacist and a lab tech..all drugs were given by pharmacy and all labs taken straight to be processed by the tech..more fun was catering was notified and they would bring everyone a meal and drinks....yup..our arrests were a catered affair.

All my US jobs were nonunion in notforprofit Catholic charity hospitals , I can only wonder how the nurses in the for profit hospitals were treated but according to a bunch of my collegues they were treated pretty well, I was in Kentucky, they were in Texas and Louisiana.

On to the thornier problem. Unfortunately government and employers don't really care all that much about researching new grad choices in employment. I think in your small rural community hospital they may see that new grads apply for certain jobs and think about it. The problem really is the employer (the hospital) has no interest in examining the effects of grad choices because grads DON'T have a choice.

As a new grad you are going to be completely limited to what you will be able to do.

If you choose to look for immediate employment right after grad you are going to be qualified for very basic nursing positions. If you are hoping to get to dayclinics/sameday surgery clinics or radiology procedures realize that you will be competing for that job with very senior nurses who want a 9-5 day job. Those really good jobs are also withheld from the general nursing pool and held for accomadated nurses..meaning nurses who have destroyed their back/hips and can no longer perform at the bedside. So you will have no access as a new grad to all the really cool positions. You will have to fight for any other positions with other new grads and senior nurses.

Here in Toronto part time is the promised land and the fight for a permanent part time position is fierce. There are fulltime positions available .

What I suggest to you before you apply for any job is to go out and get ACLS and then an ECG interpretation course. You need a recognized arrythmia course and an assessment course.Get IV certified and get good at it.

You have now leapfrogged over your peers and can be considered for a telemetry or stepdown unit for an ICU.

During consolidation go to a small hospital that has an acute ward. My consolidation was a medsurg/labour and delivery with a 4 bed CCU ward. I would give TPA in the morning and help deliver in the afternoon. Small hospitals with a good preceptor will do extras for you, you will get all the foleys and NG's and when they trust you you can start IV's under supervision and learn to suction vented patients. Stay small, think big.

The degree isn't going to do anything for you, what you need is specific education for the area you want to work in. To work in the Er you will need a ton of courses, the ICU is the same. Get the bare minimum, ACLS,arrythmia/ecg/assessment/IV's and venipuncture. If you get to stepdown sometimes the employer will pay for critical care.

Another wild and wacky way in is to find out what the driving philosophy of the hospital you are applying to is. Here we have Patient focused care..the hospital has a course...take whatever courses the hospital offers.

In your first 2 years you must be education hungry and get all the "real" credentials you need to practice. Passing the boards and getting the RN behind your name ain't going to get you a good job but all those other courses will.

You must find something about nursing that really rocks your boat, some nurses have a thing for dressings..they end up in Burns, some have a thing for patho and go to the ICU,some like heads and end up in neuro...find what you like doing everyday and that will be your source of pleasure and accomplishment.

Government/Hospital is never going to respond because all positions in the hospital have to be filled regardless. The other fallacy in your thinking is the assumption that some hospitals are not meeting the standards. No hospital or government will ever recognize that some workplaces are better than others. All hospitals are mandated to meet the standards for quality and all have quality assurance departments. Despite the fact that we all know that some units in some hospitals are a nightmare you will never hear a hospital or a government ever confirming it. You just need to listen to the spin that comes from the PR department after the surveys for satisfaction are published..they all have excuses.

So if you go into your unit and work hard to make it the best damn unit ever you will never get recognition for it because that is exactly the expectation everyone has anyway. No one is willing to admit to the public that anything is wrong and they certainly won't center out a good unit because it will draw comparisons .

Nursing ultimately is a personal thing, you have to meet the standards despite the quality of the environment.

What I am trying badly to say is as a new RN you just aren't going to get that much access to areas that hold the promise for you to uphold the standards, it will be up to you to do it.

fergus51 · Feb 24, 2004

There are training programs available to new grads in BC. Many will pay for you to take the BCIT courses in exchange for a work commitment.

I should tell you, my experience was the opposite of moia's. My first terrible job was in the US. It was beyond horrific and the people were beyond nasty. It taught me some valuable lessons! (I will NEVER work in a non-union or a for profit hospital again!). I think you need to be very careful about where you choose to work as a new grad. Ask other new grads how they fared on the unit you want to work on, ask about the turnover rate for nurses, ask about training opportunities, ask about your orientation, etc. My second job in the US was great because I looked into all these things.

As far as making a difference being a cliche.... I think that depends on where you work and how you see things. I work OB and NICU and I do make a difference, and patients do thank me, and I see the changes and it is really rewarding. The staff is good, the docs are respectful and I would put our unit up against any other unit, anytime. There are days that suck, but most of the time I love working in intensive care with my little babies.

vislandnurse · Feb 24, 2004

It is really great to hear different experiences. I don't think that one nursing experience can fit all.

One of my instructors has explained that hospitals are now offering to assist new grads to get their specialties through BCIT. My heart has always been pulled toward OBS...but my very limited exposure to the ward (only four days for now, and can choose to have a consolidation there in year 4) makes it difficult to make the decision right now. So do you recommend that a new grad go for a specialty right after graduation, or wait for awhile?

I've got to say that I think that I am fortunate to be training as part of the Collaborative Nursing Program in BC (colleges and Malaspina University College and UVic teaching the same curriculum in collaboration). It seems to be an excellent program. Lots of hands on. When we are in clinical most nurses are great to work with. They come to us when they think that there might be a skill that we would like to do, so we get exposure now. Our clinical instructors ask us for list of procedures or types of experiences that we have not yet done or been exposed to so that they can try to arrange that in our patient assigments.

The questions that you asked in your second job placement fergus are the types of questions listed in the booklet put out by the RNABC for new grads in search of employment in 'quality practice environments'. I think this resource is a great tool.