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In this episode of the Care to Learn Podcast Tracy Edwards, a highly experienced and respected Nurse Practitioner, speaks passionately about her hunger for education, the intense link between learning and the provision of quality care and how the use of preceptors has evolved in her Emergency Department...
Podcast Transcript
Wayne: From Ausmed Education, hello and welcome to episode six of the Care to Learn Podcast series. I’m Wayne Woff and each month we sit down with interesting and influential professionals working within healthcare and education.
In this episode we’ll be talking to Tracy Edwards, a Nurse Practitioner in a busy emergency department. Tracy is passionate about clinical practice and has a huge hunger for new knowledge, always taking the time to investigate what she doesn’t know.
In today’s episode we’ll discuss how, as a Nurse Practitioner, Tracy is able to pass on knowledge to her colleagues and help others to really embrace education. We’ll also touch on successful approaches to learning in a busy emergency department, potential issues that have come from regulating CPD and the strong link between leadership, teamwork and a department’s attitudes towards learning.
So, let’s get into it.
Welcome Tracy to our Care to Learn Podcast here at Ausmed. We’ll kick off our discussion today by getting you to discuss with the audience and tell us a little bit about your professional journey and how you came to become a Nurse Practitioner in the ED.
Tracy: Thanks for asking me to do this.
I started nursing in 1983, so thirty-odd years ago. I always wanted to be a Registered Nurse, but I didn’t do very well with the HSC. So, I went to Sydney, had some interviews and was told that I wasn’t smart enough to be a Registered Nurse, and that I was better off as a Nurse’s Aide. So, I went and started my Nurse’s Aide course.
I finished that and then went back home to Canberra for 12 months before my family moved to South Australia, to Woomera.
Stuck in the middle of the dessert, I was lucky enough to get a job as an Enrolled Nurse, and I was in charge of the hospital transfers in the ambulance. Then I worked in Port Augusta for 12 months until I got into my hospital training to become a Registered Nurse in 1986.
I did my three-year course through the Queen Elizabeth Hospital in Woodville and then I went into private. I decided that I wanted something different, so I went into the cardiac unit at one of our private hospitals, Ashford, where I started. I worked there for 18 months and then found myself as a unit manager three years out of my training, which was a good thing for me because then I got to see both sides.
I became the unit manager and then I got married and had children, so I moved up to the hospital that I’m at now and I’ve been there since 1995, working in coronary care.
Then in 2005 I had an epiphany and thought maybe I’d like to be a Nurse Practitioner. I’ve been studying all way through – my husband says that my hobby is studying – to get where I am and it took many years of different courses.
Then in 2008 I became a Nurse Practitioner Candidate. In 2010 when I finished my Master’s Degree I was lucky enough that I had a very progressive Director of Nursing at the hospital I work at, and she said, “you will be our first Nurse Practitioner in ED”. So, I was handed the position and I was very lucky.
Wayne: Fantastic, I should have shared my story with you briefly before we started here today as we’ve got a common career path. I started as an Enrolled Nursing student in 1982 and went on to do my general training, you said yours in 1986, mine was just a couple of years before that in 1984.
But, just picking up on your point about having that epiphany and wanting to become a Nurse Practitioner, what was it particularly about being a Nurse Practitioner that was attractive to you when you had that lightbulb moment?
Tracy: I like working in a team, in the ED team. I was clinical nurse when I made this decision, and I’d already been Unit Manager, Quality Risk Manager, I’d done a few other things. I just decided that I wanted to stay clinical and I thought that there was probably no reason I couldn’t become a Nurse Practitioner because I wanted to be able to see my patients from when they presented to when they went home. And I wanted to be able to do that lot.
ED is a very fast-paced environment, in one shift you can go through ten patients: you see them, they get better and then they leave. Whereas it’s a bit of a slower pace as a Nurse Practitioner because you are doing everything, and I like that.
Wayne: And I think it’s been a terrific evolution of the profession that that opportunity is given to people who want to stay as clinicians and not potentially become Nurse Unit Managers, DDONs, DONs et cetera. Because there are a large group of the nursing profession who are passionate about their clinical practice and want to stay in it. Would you agree with that?
Tracy: I agree, yes. I mean, I don’t necessarily get students working with me in this role, but I work from the triage area because I see what presents and I think, “I’ll have that patient because that’s something that I can see and treat”. And if I have a student there I’ll always take them along and say, “you come with me and you can learn some assessment skills and if I need any injections done, you can do the injections, if I need blood taken I’ll show you how to do it”.
So, it gives me that chance to hand on some skills to a student nurse and to show them that they could also do this.
Wayne: Fantastic. We’ll dive into our first question that has more of an education focus: do you view education differently now that you’re a Nurse Practitioner? Potentially from the view of educating yourself and also from the view of educating others?
Tracy: Not really. It’s taken me 15 years of study to get where I am. By the time I did my Grad Dip and my ED course, and I’d already done my coronary care course, and then to be a Nurse Practitioner you have to do your Master’s, and I’d also gotten management qualifications through uni. So, my husband’s idea that studying is my hobby, 15 years of study so it probably was my hobby back then.
But now, if there’s something I don’t know, I’ll always go and look it up. So, I still have that “if I don’t know it, how can I treat it” attitude. I’ll always go and look something up, read. I’ve always had that attitude. And I’d always take people aside and say, “look, how about we do it this way? Policy states this, you can still do it this way within the policy framework and it’ll be easier for you”.
I still do that with people and try and educate along the way as well, even though we have a dedicated clinical educator in the ED, I feel it’s every nurse’s role to educate people.
So, my attitude to education hasn’t changed.
Wayne: And that imparting of a hunger for knowledge is obviously a key component of how you would interact with others and get them to embrace education. That hunger for knowledge is very important from what you’ve said.
Tracy: And you do find it in some people. Some people will ask you every question under the sun and you think, “oh no, they’ve just asked me something that I don’t know. Okay, I don’t know that, but let’s go and look it up”.
And then you’ll have people that just don’t want to know, and they’re the challenging ones. They’re the ones where you have to say, “look, you really need to know this so let’s go and have a look”, or, “I’ve just read this article, so you have it now because it might show you a better way of doing what you’re doing.”
Wayne: Taking that conversation a little bit further, given the nature of work you do in the emergency department, are there particular approaches that you take to that role of staff education?
Tracy: I usually like the one-on-one because I think you can be more personable, and I find it easier to explain things to students or Enrolled Nurses or Registered Nurses one-on-one.
In the ED it is very hard to get to education. Even though we have a double staff time education session, if it’s extremely busy they don’t get to go. So, trying to get staff off to education is always difficult and sometimes you have to do it in small groups of two or three. That’s what our clinical educator does.
The other format that we use in our ED is by the way of Learning Packages. To be able to work in the resuss room and be the Airway Nurse you have to have done the package to get to there, then you have to have done the orientation, then you have someone standing there with you, so that’s more one-on-one type education.
I see that work in some aspects and in some other aspects it doesn’t work. Same thing if you work at triage, you have to do a package.
Some nurses will take it further than the package and will do more reading; some will just do the package. And you can always tell the nurse who has done the extra reading because they’re the ones that will think outside the box and will ask the odd question. Then someone behind them will say, “why’d you ask that?” and they’d say, “because of X”.
So, you can always tell someone who really wants to learn. And I think sometimes doing a learning package helps and sometimes it doesn’t. It’s a means to an end.
Wayne: Yes, as you’ve just described, for some people the package can tend to define the learning and hold it back rather than other people who will perceive it as a launching pad, as a starting point for further learning and taking those opportunities.
So, it segues into my next question in terms of what you think are the most significant impediments to staff embracing ongoing learning? In your experience across a career that spans almost thirty years, your observations across that and your current role, the most significant impediments to ongoing learning.
Tracy: I think that people think they have to do all their learning at work – some of them. And it’s not about that at all. You have to do some of the learning at home and in your own time. You can’t learn everything at work.
I think with these new AHPRA standards that have come in where you have to have 20 points of continuing education as an RN, and Nurse Practitioners have to have an extra ten, I think in some ways it’s good because it makes people learn. And in some ways, I think it can be a bad thing because they think, “I’ve got my 20 points, I’ve ticked that box, I’m done.”
Whereas I look it as a standard, a minimum standard, that you have to have.
When I have my annual PRND they always ask what you’ve done, and I use the Ausmed App for documenting my PRND because I can print it off and say, “there’s my 100 hours of learning, I didn’t do as much this year because I was sick…” But some people will hand in their 20 points and you’ll ask, “but what have you learned?” And I think that can be an impediment.
Wayne: And I think you’re quite right, that regulatory environment that will always tend to set a minimum can be both a positive and a negative within the space and I think that love of learning is something that is very personal but is also a collegial thing and a workplace thing where it can be absolutely engendered.
Let’s move now to what you would see as some emerging trends in education in the emergency department – activities, modes or methods that might be used now but weren’t used five years ago, 10 years ago, 15 years ago. Have you seen some emerging trends in terms of education?
Tracy: Not a lot in our department, I hate to say. But we do use preceptorship a lot more. In my day you never would have seen it. They would throw you out onto the floor and say that you were the RN on-duty and you’d think, “oh dear god”.
But now we use preceptors. The students will get a preceptor and they know that that’s the person who’s going to teach them and help them through their placement.
But we also now use preceptors a lot more for our Enrolled Nurses and our RNs. Now they have a go-to person. So, if they have a procedure say, they’re in the resus room and the doctor says, “we’re going to put an underwater seal drain in” and the nurse says, “no we’re not because I don’t know how to do that.” If their preceptor is on, they can go and find the preceptor and say, “I have to do X, I need help”. That preceptor will come with them, bring the procedure, show them how to set it up, make sure that the next time they’re in that situation they can say, “no worries, I know how to do this”. I think that has changed.
That’s one thing that when I went through, I didn’t have a lot of. And I think we need more Registered Nurses that are willing to take on that role so that they can educate other Registered Nurses so that they can then educated the next Registered Nurses. Because if we don’t, that old saying that ‘nurses eat their young’, it’s not a good thing. We need to push people and say, “you are a good teacher, you need to put your name up to be a preceptor of someone.
Wayne: And do you think people are warming to these roles, more people that are willing to put their hands up?
Tracy: In our department, yes. And they’re not just clinical nurses. We’ve got Registered Nurses who are preceptors, and sometimes they are the best preceptors because they’ve been there, but they’re not necessarily nurses that have been there 10 years, they can have been there two or three years.
We have some great Registered Nurses in our department who have only been there three or four years and they make the best preceptors.
Wayne: And do you think that extension of roles by taking on the title of being a preceptor tends to enhance teamwork and that sense of shared responsibility, that sense that we’re all in this together?
Tracy: I think it very much depends on the RN as well.
Certainly, in our department, we’re only a small department but we’re always busy, and there’s always that teamwork. And there’s always more patients than we’ve got cubicles for and so, “what can we do? How can I help you? I’ve done my obs for my three patients, what do you need doing?” and that comes from leadership. That doesn’t come from the RN alone. That comes from the top. The Nurse Unit Manager, the Clinical Nurses, everyone getting together and working together and showing that we’ll get through this. I think that makes a big difference.
Wayne: You just touched on that link between leadership and education. For you that link is incredibly strong by the sounds of it.
Tracy: In our department it is.
We have Clinical Nurses and the Associate Nurse Unit Managers, which is the next step up, and then the Unit Manager. So, all of those nurses are well aware of the staffing and what’s going on and who might need a little bit of extra help or education. The Clinical Educator will get involved, so the Nurse Unit Manager and the Clinical Educator will come out onto the floor during the busy times so that the staff can see that leadership – “hey, look, we’re all in this together. I’ll muck in with you, what do you need help with?” And I think that makes a big difference.
Wayne: I’ll pick up on something that you identified before that you’d previously been in quality and clinical risk roles as the Quality and Clinical Risk Manager. Given your experience in those areas, could you speak to us a little bit today about what you see as the link between quality, risk management and education, and what observations you’d make in that space.
Tracy: As a Risk Manager a lot of the stuff that comes across your desk are either incidents that have happened or near misses. Reading some of those incidents, I must admit, some of them gobsmacked me and some of them I wasn’t surprised that it had happened.
To provide quality care, you need to make sure that your policies and procedures reflect the care that is required, and that every nurse knows that if you don’t follow that procedure and something goes wrong it’s not going to hurt you, it’s going to hurt the client or the patient.
Educating nurses on those procedures and understanding what is exactly wrong with your patient, what they require and what might they require – forward thinking.
Septic arthritis, for instance, I know they’re going to need pain relief, regular obs, that they’re probably not going to be able to move around the bed so they’re going to need a risk management plan, pressure care – all of that forward thinking. Because if something happens to a patient it’s going to end up on the quality and clinical risk manager’s desk.
So, there is a link between all of those three. And it’s important that as Registered Nurses we understand that everything that we do has an effect on the patient, and it can be a negative effect.
Wayne: And I think you bring up a hugely important point that I’ve seen throughout my previous clinical career and that’s Registered Nurses’ or other staff’s intimate knowledge of policies and procedures, or lack thereof, in terms of at times we can write tomes or bibles on policies and procedures and yet they will sit on the shelf. They’re not used as an adjunct and an integral part of an education program. Do you think that’s true from what you’ve said?
Tracy: We have quite a good system, what we call the Triple-P Portal system, that has all our policies and procedures on it. So, every nurse can get on to it. Whether or not they get on to it and use it is up to them.
In my role as a Nurse Practitioner the buck stops with me. If I do something wrong, the only person to blame for that is me. So, if I have provided the wrong treatment then I have not either thought about what the right treatment was, or I might have given the wrong antibiotic, or I didn’t take a good enough history.
Trying to show Registered and Enrolled Nurses that you are responsible for that care. If something goes wrong, you can’t just say you didn’t know, the buck stops with you as well. We are all responsible for the patient. So, it’s important that you know the policies and procedures, how to do things. When you’re about to step over the line, think, “well, if I do that what’s going to happen?” Not, “it’s alright, I’m covered”. You have to have that risk mentality, that whatever you do…
After having the quality and risk job, when I pick a patient up on knee pain I’m always thinking, “okay it’s knee pain, but what could go wrong?” I have a formal way of doing things so that I tick all the boxes. And then before I discharge the patient I always think about whether I’ve covered all my bases: “is it that? What else could it be? What are my other diagnoses? When do I want them to see the GP? Has the patient got the correct care for the right thing? Is there a risk that the patient could deteriorate?”
Wayne: And I would imagine that’s a particular focus in the ED, that clinical risk mitigation in terms of the management of clients, liaising with doctors, when to escalate care et cetera?
Tracy: Yes. We actually brought in our own MET system in the ED so that if a nurse had a patient that suddenly dropped their blood pressure and it wasn’t within the correct variables, that the nurse could call, what we call, and ED MET Call. That would get you the Nursing Team Leader and the ED Consultant. You knew that if your patient was deteriorating you got immediate support. If you couldn’t find the doctor that was looking after them, you’d just call the ED MET Call and you’d get a doctor, the nursing team leader, and the patient’s care could be escalated.
We found that having that system in place mitigated a lot of risk as well.
Wayne: You’ve provided the audience and me some great insight into the areas we’ve discussed today.
We’ll just finish off with some of our traditional closing questions. The first – what’s one thing you’ve learnt in the past month that has really stuck with you?
Tracy: Never take a presentation on face-value. I’ll be sitting in at triage and the nurse is triaging a patient and they’ve booked in with shoulder pain. And you think, “is it shoulder pain? Is it something else?” Never take anything at face-value.
I’ve had a patient book in with shoulder pain and there was nothing wrong with his shoulder, he actually had chest pain, which is way out of my scope, so when we drilled down to it we moved him into a cubicle and handed him over.
It’s never just a knee, a shoulder, stitches. There’s always a story behind it.
Wayne: Never be blind to the other possibilities.
The second of our closing questions – what’s your favourite personal learning tip?
Tracy: Read and investigate. If you find something that you’ve never seen before – “the doctor says the patient has this” and you don’t know what it is – go home and find out what it is. You have to do some education in your own time. Your 20 points is not going to all occur at work.
Wayne: That sense of personal responsibility to take it a bit further.
Tracy: Yes, I think we all have a responsibility to learn and make sure that our patients get the best care. And they’re only going to get that if you make sure you know what you’re doing.
Wayne: And our final question today – what’s the best advice you’ve ever received about continuous learning?
Tracy: Probably from a Registrar who now works at Harvard. He taught me how to do a proper, full on medical assessment. And he said to me, “don’t just stop with what I’ve taught you, you always have to go on and add to that assessment”. So, here’s the basic skeleton and you fill in the blanks. He was great.
Wayne: Fantastic. We thank you for your time today, Tracy. It’s been terrific to have you with us and many thanks.
Tracy: No worries, thank you.
