As a requirement of my nursing course, am writing an essay on an incident that happened during my clinical experience. This was in a Tier 4 public hospital which serves a whole county within the republic in a densely populated area that has a population of 10 million people as per the latest censes of 2009. It also serves the neighboring counties. It has all the prescribed services of a tier 4 hospital apart from an Intensive Care Unit (ICU), and a Renal Unit of which those requiring this service are referred to the country’s National Hospital and are escorted by the nurses on duty.
I reported to work one Saturday, a day after reporting in this institution for very first time on rotation as per the nursing council requirement as partial fulfillment for the nursing degree course, in a medical ward that had seventy two inpatients the previous day. To receive us was the night duty staff who confirmed that there were only two of us to man the ward, a resident nurse and I.
As the report was being read, I noted that two patients were waiting for blood transfusion and still others needed to be assisted with activities of daily living, and at the same time it was reported from the outpatient department (OPD), that we prepare beds to receive patients from them.
After the report, those on night duty left and the resident nurse allocated the duties. She assigned me to administer medication, while she takes care of all the other duties.
I asked her how this was possible of which she replied calmly and confidently that on this day, we were “overstaffed” as most times during the weekend only one nursing staff reports and that everything was going to be just fine. She was happy to have me around!
I managed to quickly mentally adjust to this new and unfamiliar setting and hoped for the best.
We started off by assisting those that required assistance in activities of daily living and tidying up the ward and then I immediately started off with the drug round alone. Almost half of the patients were on injectable medication meaning that I had to take time to restitute and calculate the doses as prescribed, taking care of infection prevention.
The administration of drugs took too long noting that those that had a prescription of eight hourly administration of drugs as per this particular institution should get their doses between 9am and 10am but by the time I was through, it was almost 12.30pm meaning that those that got drugs after 11am were two hours late yet it was the best I could do given the circumstances as the resident nurse was busy with new admissions and attending to those that had been discharged as relatives complained of being kept too long before being attended too.
As the report was being read, I was wondering how the two of us were meant to handle all the patients efficiently and effectively in relation to patient care outcome, not mentioning that we were also meant to admit those who would present during the day. Were we going to be timely in administering drugs? How would we handle an emergency arising in the midst of all the procedures awaiting us? How could the nurse manager leave and be settled wherever she was with such a situation in the ward?
As a nurse, am aware that quality of care is more important than quantity yet these two should go hand in hand for positive productivity to be felt. Here I felt that the nurse manager had not forecasted on the staffing requirement for the unit which ought to be as indicated by the following, states,
Nursing staffing methodology should be an orderly, systematic process, based upon sound rationale, applied to determine the number and kind of nursing personnel required to provide nursing care of a predetermined standard to a group of patients in a particular setting. The end result is a prediction of the kind and number of staff required to give care to patients (Adelotte & Rousell, 2009).
When learning as a student it was made clear that two nurses should be assigned administration of drugs as a team so as to counter check on the same and as per the Kenya Nursing Council Procedure Manual 2010. Also with the blood transfusion pending procedure, two nurses were required.
I felt very inadequate and unprepared to face the day partly because I had not fully familiarized with these new environment and to me, this was a very big institution to be have had such a noticeable shortage of nursing staff. This is in reference to this institutions mission that reads
‘ To Promote And Provide Quality Curative, Preventive And Rehabilitative Health Services for All Kenyans’ making me feel that the organization in this unit did not put into consideration quality of service but rather left it to fete. According to Rousell (2009), ‘organizations exist to bring people and material to accomplish the work of the organization which should also allow for personal adjustment’, which to me did not seem to be observed as this was my second day in the said hospital.
I feared that I would not deliver quality services and that the patients would find fault in me as I felt I would keep on enquiring from the resident nurse on areas that I was not certain.
What was positive about this situation is that I worked with what I had, here meaning limited consultation. The resident nurse was very supportive with excellent interpersonal communication skills as she treated me with respect and as her equal, and provided me with a brief orientation on how to go about it, giving me confidence to take up the task with ease. I took it positively and interacted with patients very comfortably and at the end of it all I enjoyed my achievement and felt secure to undergo the same task should it so arise.
Good communication skills are essential in mentoring new staff as well as goes a long way in removing barriers and obstacles to effective teamwork (Gullatte, 2011). This was what motivated me to carry on with the assigned activity without complaining.
The nurse delegated this task to me which is an efficient time management tool and made me comfortable by reassuring me that she would be accountable and responsible to everything that I did and that she would be present in the ward in case of anything. I learnt that self-confidence coupled with a pleasant confident manager is in itself very motivating and felt I would use this skill in future.
The patients were very relaxed and some going out of their way to assist me lift those that needed a little help as they took their medication. It made me realize how passionate patients can be once they stay and get to know one another and that they feel helpful once they are allowed to assist.
What was negative is that it took too long to accomplish one assignment and that almost three quarters of the patients got their treatment late and did not raise a voice, maybe because they do not know of the right to timely services or are too intimidated to do so. This to me was an ethical issue that needed to be addressed as the full benefit of medication was compromised as a direct result of understaffing. One of the ethical issues in nursing is distributive justice meaning giving a person that which is deserved (Sullivan & Decker, 2007). They did not deserve to get medication late.
Goal setting for both long and short term are stated in terms of what the patient and the nurse will accomplish providing direction and vision for actions and time frames (WHO, 2010).
This to me had not been factored in as the duties were being prepared which left room for risks arising that would cost the patients a lot in terms of long recovery time plus maybe subject them to long hospital stay.
This hospital is a teaching institution whereby nursing and other health service providing students come for practice and internship during the weekdays and I could not understand why all the students in all the basic schools are allowed weekend offs. To the best of my understanding, this was the best time to introduce students to the unique working times of health care workers as health issues are not regulated by the time of the day but rather by the demand of the services.
I am looking at an opportunity of balancing students throughout the week in contrast to allowing them to overcrowd specific days as had been the case the previous day and overworking the resident nurse over the weekend. I feel that this would have eased the burden had students been allocated weekends as part of their training.
I strongly agree that,
Addressing the nursing shortage requires a response to the total number of nurses but also the level of nurse’s education due to the fast growing demand and complex patient care, technologies, and a widening scope of knowledge and expertise (McHugh, 2010).
At the end of the day I was left with mixed feelings on one hand that I had provided services to the best of my ability given the prevailing constraints, and on the other, that the patients didn’t get the kind of quality care meant to be rendered due to staffing shortage.
I feel that since decision making is a key function in management, this institution, should as a temporary measure incorporate students in rendering services during the weekends under supervision as happens during weekdays starting off with simple tasks and scaling up responsibilities as they gain confidence.
I feel that the nurse managers and the administration ought to call in the policy makers in this county with a well-defined document ,in it the international standards of staffing as per the World Health Organization (WHO) recommendations in the Workload Indicators Staffing Needs (WISN),
It is a method of human resource management tool that provides
health managers with a systematic way to make staffing decisions
In order to manage human resource well and is based on health
workers workload with activity (time) standards applied for each
workload component (WHO,2010).
The manager should at this sitting have found out the external standards of nursing as developed by non-nurses here meaning the county government in question as I believe they also do have expected practice by the same. This is in confirmation by Burkhardt & Nathaniel,( 2008) who have demonstrated that ‘External standards of nursing standards are guides for nursing developed by the government or institutions describing expectations of agencies or groups that utilize services for nurses’. This could go a long way in advocating for hiring of more nurses and is a better platform to effecting productive changes in the running of health services than the industrial actions that nurses undertake due to frustrations other than strikes.
According to Rousell (2009), ‘There is strong evidence that adequate number of nursing staff available to care for and coordinate care among the disciplines has an impact on patient outcomes.
I want to acknowledge here that from accounts from fellow colleagues, nursing shortage is felt in most institutions but this particular experience was almost horrifying.
The action plan for me and the entire team is to acquire the WHO, WISN manual and use this tool to make a workable staffing outline and call in the county health committee and present our findings in comparison with the actual on the ground and help make recommendations so that as the policy makers budget for the next financial year, they be advised by this document which will have been prepared by the stakeholders in addition to re- distributing student nurses throughout the week.
Burkhardt, M.A, & Nathaniel, A.K. (2008).Ethics and Issues in Contemporary Nursing. (3rd ed.).United Kingdom: Delmar.
Gullatte, M, M. (2011), Nursing Management Principles and Practice (2nd ed), ONS: Atlanta
McHugh, D. (2010), Hospital Staffing and Public Health Emergency Preparedness; Implications for Policy; DOI; 10 111/J 1525-1446.2010.00877X Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/pmc 2998349
Tomey, A, M (2009), Nursing Management and Leadership (8th ed): Mosby, Indiana.
WHO, (2010). Workload Indicators of Staffing Needs (WISN), ISBN: ISBN 978 92 4 1500197.