Running head: THE NURSING SCHOOL EXPERIENCE

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The Nursing School Experience Joseph Crossman Old Dominion University

THE NURSING SCHOOL EXPERIENCE One of the repeating sets of information that squeeze into every aspect of nursing school are the “great eights”, or the qualities of nursing that power the profession. These are critical thinking,

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nursing practice, communication, teaching, research, leadership, professionalism, and culture. I am now at the end of three years of nursing school, and I have molded these qualities into my life – one semester at a time. To give a true explanation of my time in nursing school, I will describe how I have changed in relation to each of these qualities.

Critical Thinking At the beginning of my time in nursing school, critical thinking was something that I had thought I understood. Taking data and making decision based on that data seemed no different than any other of the sciences I had encountered before – just know what actions tie into what findings. I was completely wrong. The further I progressed through nursing school, the more I understood what makes critical thinking separate from resuscitation. Instead of taking values and pairing an acceptable response, critical thinking is the creation of responses to fit a unique situation. This allows for each solution to a problem to be up to date with current evidenced based practice standards. During my year as a sophomore, I encountered my first clinical experience. I was motivated, but seriously lacking in regard to critical thinking. Of course, I did not know this at the time – I just thought that I needed more “information” to piece the picture of my patient together. For instance, during one of my days on this first clinical, I could not figure out why one of my patient’s was having her order for IV dilaudid discontinued in lieu of an oral order of Percocet. Studying the MAR during my pre-clinical nursing care plan, I could not find any reason why the dilaudid needed to be discontinued when she was consistently having pain – it appeared as though she would have needed more. In my mind, I was focused on what was on the

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paper – the effectiveness of the medication during the hospital stay. I was missing the whole story, which is that the entire purpose of the hospitalization is to increase quality of life at home, and she cannot be discharged with adequate pain medication if she is still on the IV medication instead of the oral medications. Therefore, by switching her over to the oral medication, she is advancing another step on the road to discharge. As a junior, my critical thinking was growing. During my clinical as a junior nursing student, I had a patient who was receiving two different types of diuretics, a loop and a thiazide. Both of these are not potassium sparing, which means that my patient was voiding away a lot of potassium and was at risk for hypokalemia. With this in mind, I included a focus assessment for the cardiovascular system, as hypokalemia can produce alterations in cardiac rhythms. This shows that I was analyzing what was being given to my patient, identifying risk factors, and how I can assess for those risks. I also used critical thinking to determine the effectiveness of the intervention. The patient was receiving the diuretics to assist with the voiding of excess fluid that had built up post-op. On the day in question, the patient had lost 4 pounds from her weight. This was consistent with the patient’s trend. By weighing the patient, I evaluated nursing care outcomes through the acquisition of data, and checked for inconsistencies. Thankfully, there were none that required questioning. Finally, as a senior, my critical thinking has developed quite a bit. I still feel I have more to learn, and I likely always will. During my senior clinical rotation, I showed critical thinking when deciding priority between pulling blood through a central line, or administering that patient’s pain medication who was showing signs of pain, a 7/10 using the FLACC assessment tool (the patient was not alert and oriented). My initial thought was to give the pain medication first, in an attempt to calm the patient down and quell her constant movements to allow for an

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easier time drawing the blood. However, after some thought, I realized this would be a poor decision. If I had pushed the pain medication, and then drew the blood, I would have likely pulled some of the medication along with the blood. This would have both skewed the lab results and robbed the patient of their pain medication. Nursing Practice Looking back to sophomore year, my nursing practice was not well formed. I had a good working knowledge of different equipment types and what they were for from the time we spent in the simulation lab, but once in the hospital, that did not seem to carry over very well. Between going into a patient’s room for the first time and finding out that just about every facility uses different brands of equipment – I was really lost. Of course, it seemed at the time that this was all I knew about working in the actual hospital. One thing I did pick up during this time that I am thankful I learned so early on is addressing my patient’s needs before they really become needs. This prevents the patient from having to use the call bell and wait for nurse to finally get around. If the patient has to call for the nurse, it is too late. Also, addressing things on the spot helps greatly at preventing the nurse from falling behind playing catch-up with call bells. As a junior, my nursing practice skills gained more attention to detail. Now, instead of merely learning how to survive, I was learning how to operate effectively and in accordance with protocol. In only of my logs during this time period, I wrote about noticing how different nurses followed the hospital’s protocols either more or less strictly. Some, I wrote, adhered to them perfectly – doing things like donning PPE when entering an isolation room even just to clear a pump. Others seemed to disregard the regulations very often, whenever it suits them. This is an

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example of my nursing practice extending from merely surviving, to being able to criticize the RN’s I was working for bad practice – and be confident in my practice and knowledge. During my senior year, I learned how to implement nursing practices to provide holistic care to patients across the lifespan. This was done during my pediatric nursing clinical. During this clinical, I cared for patients that ranged in age from 6 months to 14 years, and my nursing practice had to evolve along with them. For instance, with the younger patients, I prepared my medications outside of the room. I did this because I found that school-age patients would have increased anxiety watching the nurse draw up medications – which usually required a needle to withdraw the medication. Whether I was going to use the needle for administration or not, the mere presence of it would induce anxiety. In contrast to that, the teenage patients were able to understand the difference, and could be taught much easier (incentive spirometer, diet restrictions, etc.). Finally, at the adult end of the spectrum, I have tailored my nursing practice by giving more detail about teaching and interventions. Adults like to know what is happening, and using too simple of terms may insult their intelligence and come off as condescending. Communication My communication skills, I feel, have been under appreciated during most of my nursing schooling. I happen to be quite comfortable talking to people, and usually mirror personalities to connect with patients. As a sophomore, this was the extent of where nursing and communication crossed paths – talking to patients. This was particularly useful, as during this time my ability to answer patient’s questions was lacking, and being able to talk with confidence to my patient’s helped maintain my reputation with the patient while telling the patient I would have to look the

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answer up. This was the skill developed during this time period – talking to patients about their healthcare. Junior year is when my communication abilities first intersected, truly, with the nursing profession. This occurred on two fronts, both by adapting my communication to patients with special needs and communicating more with the nursing staff. One specific example of adapting my communication was with a patient I had during my junior year that had broken her glasses during her hospital stay. Her husband was going through the process of acquiring new ones, but in the meantime the patient had severely impaired eyesight. With this in mind, I talked about what I was about to do before any action. Before I entered the room, I knocked and clearly stated who I was to avoid startling her. I described what I was doing before I touched her to avoid surprising her, especially when doing blood glucose checks. This encounter made me realize just how much communication relies on sight and body language to convey a message. Not only that, but little things such as seeing who is entering the room or what they are carrying are understated in the effectiveness of communication. This was not the last evolution of my communication as a nurse. During my senior year, my communication focused less on the bedside care (which was still improving steadily) and more on the healthcare team. During this year, I gave several oral presentations to fellow nursing students and communicated with members of the healthcare team in different ways. For instance, I conducted one-on-one teaching with day-care teachers about developmental milestones using a handout. I also had planning sessions with my community health clinical group online via Adobe Connect. I also participated, during my rehabilitation clinical, in a team meeting, where members from many therapy/nursing/medical communities discussed each patient. Also, I gave a lecture in a group using PowerPoint to a group of middle/high school students (mixed audience) as part of

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my pediatric nursing clinical. The information contained in this lecture was gathered from many sources, included textbooks, online, research studies, videos, and advertisements. This allowed for a wide range of media to be presented – pictures, advertisements, videos, and basic text complimented with the oral presentation. All of these unique communication techniques show that I expressed myself with diverse groups and disciplines using a variety of media and contexts, and also demonstrated how I utilized data from a wide range of sources to enhance the communication. Teaching Teaching during my sophomore was often ineffective and redundant. This was due to mixture of inexperience with teaching strategies and a much lesser pool of knowledge to teach from. Therefore, I was really only capable of teaching basic healthcare topics, which the patients usually already knew or had been taught. Typically, I would teach patients about fall risk precautions, pain management techniques, and skin breakdown precautions. Although the sophomore year clinical rotation was shortened to only 5 weeks, these simple topics served as good experience to build on with patient teaching. Come junior year, my teaching expanded to cover several clinical topics. I was able to conduct teaching about several medical problems, but mostly diabetes management, MI/stroke prevention, and techniques for ambulation. My skills with teaching patients also improved, so I was able to have the patients retain what they were taught by being able to better judge what helped each patient learn. During this rotation, I was exposed to a greater variety of diagnoses, and gave the opportunity for a great amount of learning to take place for myself. This year saw the textbook as essential clinical equipment, and was very frequently broken out to read up on a

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diagnosis prior to giving an assessment. In one case, I was teased by fellow students because I had spent our lunch break looking up diverticulitis using my phone (I was off the unit) after spending the day observing in the OR. These examples show that during my junior year I used information technologies to enhance my own knowledge base. Once I was a senior, my teaching strategies and content increased greatly. I was now able to teach a patient about a wide range of topics using patient-specific strategies, as well as answer their questions accurately with confidence. For instance, I taught an appendectomy patient, who previously had not ambulated by post-op day 3, the importance of ambulating. The patient complained of pain and did not want to ambulate in such pain. I checked the patient’s chart and noted that a CT scan had been done to rule out a bleed (the patient’s abdomen was very distended and tender) and only gas was found. I explained to the patient that, although it is painful now, ambulating will help move and pass that gas that is causing such pain. Therefore, by ambulating, the pain will start to dissipate. After this teaching session, the patient agreed to ambulate. By using the results of the CT scan, I used information technologies to focus my teaching to this patient about their health. Also during this year, I conducted the lecture to middle/high school students that I mentioned previously. In this lecture, I used a PowerPoint and taught about reducing risks for several disease processes – mainly about heart disease prevention through nutrition. By doing this, I used more information technologies (the PowerPoint contained graphs, videos, etc.) and taught about risk reduction in a pediatric population. Between teaching adult patients about their disease processes and teaching the middle/high school students about risk reduction, I used information technologies to teach various topics across the lifespan. Research

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Reading and understanding current research findings was not an integral part of my sophomore year. I had very little understanding of research, how it was conducted, and it made a difference in clinical practice. Of course, this year included research in almost everything, but I just was not able to make the connection. In fact, the clinical logs required research articles and, looking back, the articles that I picked were not primary research at all, but instead were descriptive literature. Luckily, by junior year I was able to distinguish between descriptive literature and primary nursing research. This is evidenced by my clinical logs which, at this point in time, contained primary nursing research in them – instead of non-research articles. During this year, I also brought in a research article to clinical after having a discussion with the nurse about whether wearing compression stocking and SCD’s together increased their effectiveness. As it turns out, it does, and I had a randomized control trial to back it up. The trial found that patients using both SCD’s and compression stockings together had lower risk than those wearing either the stockings or the SCD’s alone. During my role transition in senior year, I was able to allow current research to fuel my nursing practice. This is largely due to increased independence present in this clinical rotation, which allowed for me to develop my own practices in line with the research I have studied all along. For instance, I had remembered research findings from a previous clinical when my preceptor made a comment that he did know why they include a gas bubble in pre-measured injections of Lovenox. I explained that the gas bubble was found to increase the accurate administration of the medication. Without the gas, there is a likely chance that some of the medication will remain in the needle or syringe, and not be injected into the patient. In the study, they found no significant side effects to the injection of the scant amount of gas – but did notice

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a different in administering the full amount. Therefore, it is evidenced based practice to include the gas bubble in the administration to ensure the full dosage is administered. In this example, I was able to recall and apply research findings dynamically, and not just in structured situations where I look for research to fill a specific void. Leadership During my sophomore, my leadership abilities did not extend into the nursing profession. To say I did not possess leadership would be false, for by this point I had already received quite a bit of training and experience through NROTC. What I still had to learn, however, was that leadership in the nursing profession is whole different breed. I learned this during my first clinical, when I walked onto the unit and realized I absolutely did not have the knowledge required to adequately lead anybody in nursing. Throughout my junior year, however, I started to overcome this obstacle. As I increased my knowledge of nursing and how the hospital operates, I was able to slowly expand my leadership experience. During this time, though, I did not take advantage of leadership opportunities much greater than enlisting the aid of other students to assist with ambulating a patient. However, while leading my peers during these evolutions, I assumed a leadership role in my scope of practice, and while coordinating the team to meet the needs of the patient – I maintained responsibility for the patient. My leadership really began to take form during senior year. This year was when a dedicated leadership class took place, and community health gave leadership opportunities continuously. One such opportunity was during the administration of the Denver II developmental screening to the children at Noah’s Ark Daycare. This was part of our project to

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determine the developmental stages of the children, and teach the staff at the daycare how to also determine the developmental stages. When we arrived at the daycare, there were lots of children to test and many moving parts. I took the initiative to organize the group together and delegate each person with a set of tasks/children to test. In the end, we were able to test all of the children with accuracy and in the time frame allotted to us (3 days). This was an example of me delegating and supervising a nursing intervention. Professionalism In the beginning of my time in nursing school, I understood the importance of professionalism in the profession. One example of my emulation of this understanding was, during my first clinical, I had trouble hearing my patients breath sounds. Instead of passing the issue up as “normal”, I sought out my instructor and asked for assistance – even though it made me appear not very skilled to my patient. This led to me getting one-on-one instruction on my technique, gave me accurate information, and was overall the right choice to make. During junior year, my time management skills began to become strained. This stretched over into my clinical experience, and my professionalism was what kept myself on time, in the proper uniform, at the right place. This sounds quite simple, but between increasing expectations in NROTC and nursing, my hands were quite full. There were several instances that I reached out for assistance during the clinical day, and my professionalism kept me on track. I was kind and respectful to my patients, instructors, and fellow students. My true growth towards the profession occurred during senior year. During this time, professionalism didn’t just mean doing what I was supposed to with respect, but partaking in events going on with the nursing profession. One example of this was during community health

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when I wrote a letter to Delegate Leftwich of Virginia, regarding a bill that would make patients having access to their electronic medical records upon demand a right that the health systems must oblige. In this letter, I cited research from the Annals of Internal Medicine that showed a patient’s ability to view their medical record benefits both the patient in their own independence, and benefits the hospital by allowing the best critic (the patient) to review their documentation outside of a court room. This is an example where I advocated for the professional standard of practice using the political process. Delegate Leftwich wrote back to me stating that the bill had passed on the Senate, and that my letter was helpful. Culture Even from the start of sophomore year, I knew that culture was important to nursing. It seemed obvious, since a lot of medical breakthrough meet opposition in religious communities. This was about the extent of my understanding of how culture met the nursing profession. What I learned during this year was that a patient’s culture very much defines their entire hospital stay. Therefore, with this in mind, I made it a habit during this year’s clinical rotation to include culture in my assessments and include it into my care plan – even though I was not very good at it quite yet. I discovered that what I needed to better assess culture was time and exposure. Therefore, during my junior year clinical rotation, I became more in tune and culturally sensitive with my care. I also began to notice how my patient’s culture could impede/aid their medical care. One of my clinical logs during this year featured a research article that related to culture. There was a study on the need for blood transfusions after a hip replacement surgery. The studied showed that patients who had blood transfusions post-op were more likely to recover from the surgery,

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because the boost in blood hastened the recovery process and got the patient to rehab faster, and time is important to avoid the buildup of scar tissue and maintaining flexibility. A patient that I had during this rotation did not desire the transfusion for blood, and was slated to receive a hip replacement. I did have the patient in the future and did not find out what eventually happened to the patient, but if she stuck to not wanting blood transfusions, she was limiting her potential postoperatively. This shows that I was considering the impact of research outcomes on persons form different cultural backgrounds. Finally, during senior year, my cultural understanding continued to increase. During my community health clinical, I was exposed to people from several different cultural backgrounds, and was given the opportunity to spend time with them and increase my understanding of their culture. During my role transition, I realized that very few of the patients in the hospital share in the culture of healthcare providers. Therefore, most patients are in unfamiliar territory in the hospital, and look to the nurse to be their guide through their hospitalization. After this, the way I conducted myself with the patients was geared towards increasing their comfort in an unfamiliar environment, and I noticed a great increase in friendliness and understanding with the patients. Conclusion My time in nursing was a very difficult and rewarding experience. I learned a great deal about myself, the nursing profession, and how society treats healthcare as a whole. The reality of nursing school was not quite what I have envisioned it. I picture that I would start school knowing nothing, and leave nursing school with all the knowledge needed to face what lies ahead. The change was much more subtle, and in the acute phase I do not feel I have progressed. However, when I look back to where I was when I started, I can see just how far I have come. It

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makes sense now, that nursing school isn’t some magic solution that pumps out competent nurses. Instead, it is a guide for those who are ready to learn the material, and fight for it every semester. I was able to acquire many skills in nursing school, from ambulating patients and changing their sheet while they stay in bed to more advanced things, like starting IV’s and the entire science behind the administration of IV medications and fluids. I feel that, now, I am ready to face a new grad position as a staff nurse with only a short orientation, as nursing school has taught me how to learn new information effectively. My strength, right now, is my motivation. I feel ready to take on the world – if nursing school did not stop me, nothing can. This will help me orient and focus on whatever field of nursing I end up in. However, an area for improvement that I have identified is my time management. I have made leaps and bounds in nursing school managing my time, but I feel that most assignments where still done at the last minute – and on the floor of a hospital, this just does not cut it. As a new grad, my learning needs will be specialty specific nursing, since I do not yet identify with any particular nursing area like some of my fellow students. Also, as mentioned, time management skills are still on my learning needs list. I am both excited and honored to complete nursing school, and fully intend to find myself in the academic setting again one day – after I can mentally recover first!

THE NURSING SCHOOL EXPERIENCE Honor Code

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“I pledge to support the Honor System of Old Dominion University. I will refrain from any form of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a member of the academic community, it is my responsibility to turn in all suspected violators of the Honor Code. I will report to a hearing if summoned.” Electronic Signature: ____Joseph W Crossman___ Date: _17 APR 2014__