Examples of Each Level of Practice
The following are examples of each level of practice, from all groups:
Novice. Incidents classified at the novice level referred to graduates who felt they could not cope with a specific situation or situations in which they saw something going wrong but did very little about it. In some cases, even after the incident, these graduates did not follow up, try to find out why things went wrong, or try to correct the situation. This example is from a graduate from the control group whose description of a significant experience was rated at the novice level of practice:
During the change over [of shifts], at 6:45 in the evening, we found that there was fetal [heartbeat] at that moment, and the mother suddenly became fully dilated. We asked the doctor because we were no longer allowed to deliver the patient if it was a breech presentation. Then we found a doctor who assisted us. We were encouraging the mother to push at that time, but she couldn’t push well.... I thought that the doctor would manage the way I learned when I was still in training, but he didn’t pull the cord; the cord was left inside, and then when he pulled the baby out, then the baby came out dead.
When asked what his role was at the time, the respondent stated that:
At the time, we clamped the cord and cut the cord. We tried to resuscitate the baby, but we failed. Then we came back to the mother, and we told the mother that the baby was not alive, and the mother just cried, and then we tried to reassure her, and we tried to tell her the cause of the death. We told her that she took so long to push the baby out that there was cord around the neck at that time. Then we told the mother that if the cord is around the neck then there’s little chance of the baby to come out alive. I would say, according to my assessment, there was mismanagement.
This graduate’s description of the significant experience is indicative of novice stage of practice in that he not only witnessed “mismanagement” of a breech delivery by a doctor and failed to intervene on behalf of the patient, but continued to blame the patient in his explanation by telling the patient that she took too long to push. In his own words:
Sometimes it becomes difficult to tell the doctor and say, “No doctor, do it like this.” I couldn’t say something about it. I continued encouraging the mother to push. I think it was a doctor’s role to know the management of breech delivery.
Advanced Beginner. The incidents classified at the advanced beginner level do not describe unsafe practice, but instead describe nurses who asked a more experienced colleague to intervene rather than handling the difficult situations themselves. Such nurses participate in interventions, but neither take the lead nor do anything special to help.
In this example, the graduate (from the PBL group) saw something going wrong and brought it to the attention of the doctor, but the doctor did not respond adequately. The nurse remained involved and did her best, but the patient died:
The only case that we had last month is a patient who came in as an emergency case. The indication, she was cesar [sic] for [inaudible] ward, and she was in labor. This lady came with [inaudible], and she was, like, 36 weeks. She came with a high temperature, and you know, the blood pressure was high, high, high; it was, like, 180/120. And, you know, if you talk to anesthetics doctors, “You know, doctor please check on this BP [blood pressure] ‘cause it’s not alright,” he turns like, “OK, you know what [name], this blood pressure has been like this before, and you know, our machines are not all right ‘cause if the patient is shivering [inaudible] become alright, you know, so you have to make the patient cool so as to get the right reading.”
So I thought the patient was stabilized, and she became OK; she was cold, but the blood pressure remained high as we proceeded with the cesarean section. I don’t know if the patient became disoriented. ‘Cause you know we keep on talking to them so as to be sure that the anaesthetic that has been given doesn’t do the wrong thing. So I was talking to this patient, “What baby do you want?” She said, “I don’t know.” “What’s your name?” “I don’t know.” “Where do you stay?” “I don’t know.” What’s the name of the father of the baby?” “I don’t know.” I said to this doctor, “You know what, this patient is getting disoriented, and I don’t know, maybe the spinal, but I’ve never heard of the spinal being [a] cause of disorientation.” So he said, “Anyway let’s carry on ‘cause I think she doesn’t want the baby; maybe that’s the reason why.”
So at the end of this cesarean section, after they’d closed and done everything, and she [the mother] was sent to recovery room, I had a report from the sister [the nurse in charge of the unit] who was working in [the] recovery room, and the patient was bleeding [from her] vagina. We had a doctor there in our duty room, so he went there and checked the patient [inaudible], but the patient continued bleeding, bleeding, bleeding.
So, at that time, the oxygen level in the blood was, like, I can tell you I didn’t get the readings from the book or from the notes, but they said it was, like, 77 or so, but far below the right level of the oxygen. So that patient was transferred to high care after the doctors had got to the [inaudible] the GCS [Glasco Coma Scale] of the patient is not alright; she is getting disoriented. The oxygen saturation is low, BP remains high, but [she was] still bleeding, so they ordered bloods for the patient and transferred her to [the] ICU [intensive care unit], no not ICU, maternity high care; it’s just closer to our theatre.
So as they were transferring this patient to high care, the patient started gasping as if she needs air, so they turned back with the patient, ‘cause in high care, they said they don’t have a bed ready for the patient, so they had to take the patient to our theatre for oxygen and all that [resuscitation]. So the patient was resuscitated and was kept on [a] ventilator and then later was taken to [the] ICU.
So that patient survived for two nights; no, on the second night she passed away, and now we’ve got, like, a blame ‘cause, like, it’s like we didn’t care about the spinal; maybe the spinal went up, instead of doing work at the bottom there, and then they say we were not careful ‘cause we didn’t care about the oxygen level and that the patient was bleeding. But that was sorted out ‘cause they spoke to this anaesthetic doctor, and he said there was no indication that should cause him to suspect the spinal injection to be problematic.
Competent. The following example shows the graduate analyzing the current situation in the light of the past, while at the same time, making plans for the future. She makes her own observations and acts on them with confidence. Other incidents classified at the competent level showed a nurse immediately responding to a patient’s needs, even when it was possible to delegate or refer and a nurse managing difficult situations according to expectations, either on her own or as a team leader. Nurses at this level were willing to bypass unresponsive doctors and assertively confront colleagues if their behavior was unacceptable. These nurses may also be competent in procedures only expected from nurses with specialist training. A PBL graduate working as the only RN in an acute psychiatric unit described the following incident:
Well, we had a difficult patient who was getting very physical with another patient. I managed to actually calm the situation, calm him down and get her out of there and away from the situation. I spoke to them individually, and by the evening, all was calm. But I got the doctor to write some medication up for him just in case he gets agitated again during the night. But I actually managed him [the patient] well enough not to have to resort to giving him medication. You know, just by talking to him and explaining things to him and things like that. He actually managed to calm down without me having to use medication or force.
Proficient. There were a few incidents classified at the proficient level. They reflected a nurse who anticipated a client’s needs based on her own assessment and acted accordingly. Often, these actions were anticipatory and saved time later on in treatment. In one case, the nurse went against a doctor’s direct order and was proven correct. A PBL graduate described the following incident:
Recently in the ward we had, I was on doctors round, and the doctor made a decision to induce a [pregnant] lady. We’d been monitoring her fetal heartbeat every day, and all of her traces hadn’t been the best. They’d been subnormal because she was only about 33 weeks, but her baby had growth retardation, and she [the mother] also had high blood pressure. So we expected the fetal heart rate not to be the best, but we had to put her [the mother] on oxygen and put up a drip before it would actually improve.
The doctor made the decision to start inducing her. And I showed him the traces, and I said, you know, I really don’t think we should waste our time around with induction; her CTGs [cardiotocographs] haven’t been the best, and more than likely, when we do induce our high PIH [pregnancy-induced hypertension] moms, they end up having problems, and we inevitably take them for [cesarean sections]. And he said, “No, go ahead just do a fetal heart trace first, and then we’ll induce,” which I did.
Within an hour or two after inserting the first set of Prostin, I put her [the mother] on to the fetal heart rate machine, and the fetal heart rate started dipping; it had deceleration signs, so I thought, “Oh, here we start with the problems.” So I put her on oxygen, and I put up a drip, and I put her onto lateral, which is all the procedures we have to follow. I managed to phone the doctor, and she wasn’t able to come to the ward at that time. She said just to leave the patient on for 20 more minutes after oxygen and to call her. I actually didn’t even bother doing that. I prepped this patient for [a cesarean section]. I called the intern to take consent, and we got cross match for blood, did the FBC [full blood count], checked her BP because I basically knew from working these types of patients that she was going to end up a cesar.
I phoned the doctor again, and I said she’s OK bring her. So I think that illustrates problem solving where I thought ahead, and I actually just prepped the patient for cesar, and I saved a lot of time. Luckily ,the baby was fine. Because sometimes you know by waiting 20 minutes and then only prepping for cesar and putting the catheter in by that stage the fetal heart rate’s been going for this long, and there’s been a lot of...is not good enough.
Respondents were asked about their feelings related to the incidents. The majority felt good about the incidents they had described. This is not surprising, since most of the incidents spoke of mastery, competence, and good performance. In some cases, the respondents’ feelings during the incident were not as positive, since graduates were tense and worried when they had to manage challenging situations. Afterwards, however, they felt satisfied and proud. One PBL graduate stated:
Relief when we got him breathing again. I don’t think there was time to panic at all; it was a more of a step-by-step prioritizing, what you were going to do first and sorting it out. So with each hurdle overcome and, like, first of all the sats [oxygen saturation] being maintained and everything, it was, like, relief that you were actually getting somewhere. You felt like you were doing something of significance.
However, there were exceptions, when an incident led to ambivalent, conflicted feelings or feelings of being scared or angry. This example from a PBL graduate demonstrates ambivalent feelings:
I was very worried about this child.… I felt very helpless.… I did not know whether I must phone the doctor...must I put up the drip...and I was unsure...but I was just happy afterwards that I did what I did.
Another PBL graduate described guilt feelings:
You always feel guilty, specifically because you are new in a ward.
This example from another PBL graduate shows angry or scared feelings:
At that point I felt scared...traumatized with the patient to be resuscitated...dealing with the family...that got to be emotionally…. But I think I felt a bit angry...throwing me into the deep end.… Management should know I am newly qualified.… Can’t someone come and help me from other wards…because I felt at that point I was not safe...competent enough a practitioner...but somehow I was.