My advice for nurses after more than 30 years of nursing

Meet Natalie Smith! “My advice for nurses” is possibly one of the most in-depth, must-read articles so far. It epitomises senior nurses sharing raw and practical experiences with others. Thanks, Natalie for being so kind to share so much. Natalie has written for us about a range of topics. Check out “Reflections on leadership and nursing education after 30 years” and “Unique Overseas Nursing from Saudi Arabia, England to Vanuatu in the 90’s“.

Introduction

Hi, my name is Natalie Smith. It’s hard for me to believe I am now in my 50s and have been nursing for more than 30 years. Training in Queensland, just before nursing education moved to university, we were inducted into the nursing profession quickly. During our three years of training, we were rotated between different clinical settings to meet the curriculum requirements and improve our versatility.

This built resilience and flexibility, and helped us to determine the areas of interest for further development. My desire for learning and critical thinking led me into a career in Critical Care. For most of my career, my professional identity was as an Intensive Care Nurse and Educator, although over the last few years I have been branching out into Emergency nursing. I am also still fortunate to continue to teach nursing as a sessional academic.

Where do you come from?

I was born in Victoria but in all honesty, I am not a Victorian. My parents were born and bred Queenslanders. To say I grew up in Queensland would be half true. My father was in the Royal Australian Air Force (RAAF), and we moved frequently during my younger years. By the time my brothers and I were in high school, it was time to settle down for the latter part of our schooling.

Travelling around helped me to learn to be resilient and adaptable. I was forced to socialise with others and make new friends. In many ways it was also challenging. At the end of each posting, we had to leave our friends behind and change school systems, as the national curriculum had not been introduced. With every move to a new state or territory came a whole new set of learning guidelines.

Apart from moving interstate, we were also fortunate to travel to Malaysia where my father worked for three years. As a seven year old, I learnt so much more than the 3 ‘Rs’ (reading, ‘riting and ‘rithmatic). Culture was all around us. In the 70’s, this was a unique experience that very few Aussie kids had. Our senses were heightened with new tastes, smells, sights and sounds.

Living in Malaysia meant going without the normalcy of home including visits from family and foods such as vegemite and fresh milk. But we acquired new tastes and talents adapting to the strange environment. Daily trips to school involved a bus and ferry from Butterworth to Penang, as there were no bridges back then. The local wildlife included free range monkeys that would steal your personal items. It was in Malaysia that I started my journey with the Girl Guides as a Brownie. The Guides provided a consistency that was interchangeable between every new address both in Malaysia and back home in Oz. Guiding taught an array of indoor and outdoor skills, leadership, collaboration, self-management and commitment. These life skills continue to be a part of my identity.

What keeps you busy outside of nursing?

Married now for more than 20 years, my husband and I have 2 beautiful teenagers and 2 mischievous spoodles. Growing up with a creative mother and grandmother has influenced my artistic side. I enjoy music, crafting and sewing. I learnt a variety of instruments during my youth and have further explored vocal and guitar tuition in more recent years.

I am an animal lover, which stemmed from my childhood; we were never without a dog or cat. My mum bred Siamese cats. I remember being woken at night to come and see the kittens being born. We learnt about love and loss, life and death and the importance of caring for something other than ourselves.

Advice for Other Nurses

What’s your secret to a long and successful career in nursing?

There are many reasons for my long career in nursing. I do not think they are secrets. In fact, there are so many sources on the topic of longevity that this should be included in the training of new nurses to guide them in their career for self-preservation. For me it is important to remember why I became a nurse.

I always wanted to work in a caring profession. As a Critical Care nurse, I feel privileged to be involved in the patient journey. Our patients and their families are at the most vulnerable stage of their lives. We guide and support them through this time. Importantly, understanding who I am and what I believe enables me to provide the best care in the right environment.

• Balancing work and life can be challenging when you have a strong sense of work ethic. In nursing, we often care for others before ourselves. When the unit is busy, we work through breaks. We stay back after the end of the shift and work unplanned overtime. Planned overtime is often requested, guilt overtakes our senses and we agree to stay.

There is an emotional burden to stay and support my colleagues when staffing is tight, however I can now recognise my limitations. I am not a ‘super nurse’. I am not the only option to fill the shortfalls. I have to consider my health, family and life outside of work. If I keep saying ‘yes’, then the need to find other long term staffing alternatives are not explored by the organisation.

• Endurance in nursing can be fostered through learning development opportunities. This provides concepts to diversify your thinking. Seeking and receiving professional development is important within the work environment, as it builds individuals within the team, and therefore builds stronger teams (Waddill-Goad, 2016).
• Every employee has a role in exploring and sharing research and best practice in clinical and non-clinical capacities, leading to positive change and a happier, healthier workplace. In more recent years I have been fortunate to broaden my horizons in leadership, communication, EQ and team building, providing a new found interest in the broader scope of nursing. I have seen quality initiatives change the focus of a team, turning it from a culture of blame to a culture of accountability.

• Taking breaks away from the workplace will help to renew your enthusiasm. Consider a secondment break as this allows you to explore other aspects of health that can add to your repertoire of knowledge and skills. It can make you more employable and also gives a different outlook on resourcing and systems within the organisation. With this new perspective, you can return to your original position feeling refreshed and recharged.

• Regular holidays are another important solution to foster longevity in nursing. Plan ahead and book your leave in advance. This is important for your supervisors managing rosters and backfill. It is also great to have something to look forward to. It may be tempting to take all of your leave allowance at once and go off exploring the world (post-pandemic!), but to do that you need to save your leave, which means you are not having frequent periods of time off. When breaks aren’t taken, we are more likely to have burnout.

• On the topic of burnout, it is important to recognise your stressors. They vary between individuals and our level of resilience. If they are not resolved, then burnout is guaranteed. Waddill-Goad (2016) discusses a different set of the 3 ‘Rs’; rest, recover and refuel. Practice regular self-care, such as exercise, time out and meditation. Most importantly use the Circle of Influence model (Covey, 1989), to accept that some things are outside of your control and are not worth worrying about.

What makes a good intensive care unit nurse?

A common belief is that ICU nurses are often known to have Type A personality; they have traits that make them more attracted to specialised environments. These traits include a drive to achieve, sometimes pushing the boundaries of being workaholics.

The importance of striving for excellence should be something that all nurses want to do. But in critical care units, this desire for learning is unmistakeable. Having a keen interest in the physiology and pathophysiology of the patient’s illness helps them to critically analyse the patient’s condition, linking theory to practice.

For many years in intensive care nursing, I have noticed key attributes that help to make great ICU nurses. At the bedside, attention to detail is very important. A messy work environment often leads me to believe the nurse is more likely to make mistakes and miss important information. Critical Care nurses need to be thinking ahead, picking up on minor changes that occur throughout the shift to prevent further deterioration of the critically ill patient. A messy environment also correlates to poor infection control practices, which leads to an increased risk of infection in patients (Munday, 2021).

Clear communication is also vital when working in a highly stressful environment. Changes to a patient’s condition need to be articulated in a way that leaves no room for error, as treatment plans will be directed from this information. Nurses also need to express a compassionate bedside manner as this is an important skill in humanity, i.e. empathy. This is one of the key factors in emotionally intelligent people, and is essential in nursing.

During interviews, applicants that stand out are those who discuss the patient at the centre of their care, acknowledging the national standards, best practice and holistic care. Candidates should also demonstrate the value that they will bring to the unit if they are successful. These qualities include knowledge, skills and traits that demonstrate their EQ such as self-reflection, self-awareness and how they manage their emotions and stress.

Acknowledging your deficits is important but having a plan to improve demonstrates to the interviewer that you have considered your future goals of learning. Using reflection will help to identify both positive and negative traits, which you can then focus on to make future improvements. Importantly, don’t forget to ask for help when needed. The teams in Intensive Care Units are full of very smart people. Tap into their brains, then go away and do your own research so that you can embed the information into your knowledge.

What advice do you have for junior nurses and nursing students in particular on dealing with death?

As hospital trained registered nurses, we were inducted into the nursing profession quickly.

At nearly 19 years of age, my first ward offered a steep learning curve in caring for sick and dying patients. Just after completing an eight week induction course into nursing, I was sent off to work on the male medical ward as a first year nursing student.

 In the whirlwind prep course, we sat through hours of lectures and practiced fundamental clinical skills, such as making beds, feeding, bedpans and vital sign monitoring. We were then expected to cope with new experiences in abundance, without the maturity, mentorship or knowledge to support us. During this time I was presented with my first patient respiratory arrest and my first of many patient deaths.

So how did we cope, you ask? Probably not well in reflection to what I know now. We went out drinking and dancing the nights away, surviving on minimal sleep and for some, barely scraping through the course requirements. Some students failed, others decided nursing was not for them, and so they moved on to new adventures. For me, I was determined to make it. Initially, the emotional toll was considerable, however over many years of nursing I have found strategies to keep me sane.

1. Accept that where there is life, there is death.
   1. Understanding the natural life cycle helps our scientific brains to validate the process.
   1. Learn more about death, so that you can feel comfortable being with patients and their families as they come to the end of their lives.
   1. Consider writing your eulogy as this will help you to reflect on your life so far and what you consider important for the future (Covey, 1989).
2. Accept that you are human and have emotions.
   1. Learn how to manage your emotions in the workplace. Develop your EQ.
   1. If required, step away from the patient and their family to reset your thoughts, take some deep breaths and reflect on your emotions.
3. Debrief with people you trust and who understand the situation.
   1. Allow yourself to cry if you need.
   1. Sometimes a good cry with the support of another can help to alleviate distress.
4. If offered, attend debriefs at work to discuss the incident or death of a patient.
   1. This will help you to unpack the situation, so that you can move on.
5. Allow a short period of reflection after an incident or death.
   1. Journalling is a great way to unpack an incident.
6. Set physical and emotional boundaries in the workplace to avoid close attachments to patients and their families.
7. Work life balance.
   1. Establish goals for living and working.
   1. Leave work at work.
8. Self-care
   1. Daily exercise – exercise increases your endorphins which can act as a natural analgesic and help reduce stress.
   1. Sleep is important for emotional regulation (about 8 hours/night) and aids in learning, memory and creativity.
   1. Music Therapy such as singing, dancing, listening and playing.
   1. Read fictional books to help you escape the realities of life.
   1. Watch movies (Avoid work themes such as ER, Grey’s Anatomy, The Good Doctor etc.).
   1. Regular massage may or may not be helpful to relieve stress and help you relax. It is individualised, and may require you to try out different styles or therapists.
   1. Regular catch ups with friends and family – do not talk about work!
   1. Practice culture and faith, if your belief systems allow. Spirituality is individual and can help you to make sense of life and death.

Looking to the Future

Where do you see the future of nursing? What do nurses need to do to ensure they remain current?

To say the last 18 months in health have been confronting would be an understatement. The pandemic has raised so many questions in relation to what the future might look like, both nationally and globally as we move into a long road of health care and recovery.

Nurses are being asked to be more versatile. Upskilling is occurring in ICUs where ward nurses and retired staff are buddying alongside specialist nurses. Pop up fever clinics and vaccination hubs are offering another skill set for the nurse’s repertoire. Telehealth, digital informatics and robotics are intensifying.

A focus on preventative health will be needed as we move into the future post-pandemic. Primary health care is such an important preventative service, but invariably not perceived as available for all who require care.  More primary health services in various forms are needed now more than ever to take the strain off Emergency Departments, as large cohorts of patients, mental health in particular, is skyrocketing (Australian Government, 2021). This has been reinforced recently in an independent review into nursing education (Schwartz, 2019).

Nursing leadership has been undergoing transformational change throughout my career and will continue to develop. Gone are the days when the Matron of the ward would yell at you as you were walking down the corridor because your shoes were noisy, or you found yourself hiding in the pan room as she was in a bad mood (I speak from experience!).

Leaders are now being developed from undergraduates through to executives. Organisations no longer tolerate poor leadership. There is an expectation that staff will regulate their emotions and develop humanistic traits, such as tolerance and acceptance. Future nurses will need to develop these skills if they want to progress in the workforce.

Reflecting back at health care in Australia pre-COVID, health care in some marginalised groups were under review; such as Aboriginal and Torres Strait Islander, mental health, disability services and aged care facilities. They were at the forefront of our minds with shocking revelations of patient neglect being aired on television and Royal Commissions being established to attempt to rectify the harm caused by inadequate systems.

This huge body of work is still being actioned both locally and nationally, and will require amazing leadership in health to achieve change that demonstrates the importance of a system where people are not numbers, but faces in our community (Australian Government, 2018; Australian Government, 2019; Victoria Government, 2021; Commonwealth of Australia, 2013).

For me this is overdue, as my father was on the receiving end of neglect in an aged care facility. The feeling of betrayal by the ‘system’ will always be with us, as we saw a rapid change in his health and then a slow decline until death. For my family, this betrayal will not ease until we see change.

If there’s one thing you could change about nursing, what would it be?

If there is one thing I would change in nursing now it would be that qualified nurses could assimilate more easily between facilities throughout Australia. Unfortunately with cross border nursing, there are challenges of skill transference, integration and acceptance. As a former Educator in an organisation, I recognise the challenges of integrating staff from interstate and regional facilities.

Health services often rely on ‘ticking the boxes’ to ensure mandated training and orientation are completed, as this is how organisations manage risk and comply with the health and safety of patients, visitors and staff. Competency-based training and assessment is often used to ensure employees are fit for work when commencing and progressing through the institutions policies and procedures.

For personnel that live in border towns, assist with disaster or pandemic relief or move between states and territories, this poses huge training requirements to be ‘work ready’ as per the organisations requirements. For example, a specialist nurse may have to complete mandated training for each organisation in which they work and the speciality specific training to achieve a level of ‘acceptance’ in their new workplace. If working across facilities, this becomes an enormous burden for the individual, and resource draining on the health service.

Recognition of Prior Learning (RPL) is one way that employers can assist staff to ease into a new environment. This may seem like a seamless approach to acknowledging past experience, however, the individual is still required to navigate through realms of paperwork. In the words of a past supervisor, “if they have the endurance to fill out the request for RPL, then we may as well give them accreditation”. I found this response confronting on more than one level.

Since the formation of the Australian Health Practitioner Regulation Agency (AHPRA) in 2010, a national approach to registration, frameworks, education and accreditation has continued to evolve. Currently, the National Safety and Quality Health Service (NSQHS) Standards are being used to improve safety standards nationally.

Recently, new clinical care standards for the Management of Peripheral Intravenous Catheters have been developed and are now accessible through the NSQHS website (Australian Commission on Safety and Quality in Health Care, 2021). There are also other national training courses that help to align practice, such as Bloodsafe, Hand Hygiene, Life Support and Trauma.

The possibilities of clinical care guidelines in the future are immense and I challenge nursing leaders to move toward a national approach in knowledge, skills acquisition and assessment on a deeper level. This will improve consistency in healthcare and allow those that wish to move between health services to do so with ease and without bias.”

What’s next for your career?

This has probably been the hardest question to answer as I have spent so much time pondering where to next. As I look to my future in nursing, I see so many possibilities. I need to remind myself to ‘be brave’ and try new things. It is important for me to remember that I am not ‘just’ an Intensive Care or Emergency nurse, my passion for which is still so strong. I still feel like I have so much to give. As an Educator, the question of a PhD is one I have been asked and yet to answer.

I love being part of the next generation of nurses, and by teaching I feel I am giving back to the profession and also staying abreast of a progressive health system. In some ways, my sea change north has slowed down the process to work towards my PhD, as I have left behind some great supports and now need to build up a new network of connections.

One of the many things on my bucket list includes exploring our amazing landscape. As a nurse this is made more possible through rural nursing contracts, which appear abundant at the moment. When the time is right, I expect I will be exploring our lucky country again soon. However, the most rewarding experience for me was volunteering.

Initially, I will stay close to home, but once safe to travel overseas again, I will consider opportunities similar to Open Heart International or Mercy Ships. The importance of acts of kindness is deep seeded from my youth with the Girl Guides, as a nurse and Christian. In the meantime, I have started making inquiries to volunteer locally to support marginalised Australians with reduced access to healthcare.

References

• AHPRA. (2021). Framework for assessing standards for practice for registered nurses, enrolled nurses and midwives. Nursing and Midwifery Board. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Frameworks/Framework-for-assessing-national-competency-standards.aspx
• Australian Commission on Safety and Quality in Health Care. (2021). Management of Peripheral Intravenous Catheters Clinical Care Standard. Australian Commission on Safety and Quality in Health Care. https://www.safetyandquality.gov.au/standards/clinical-care-standards/management-peripheral-intravenous-catheters-clinical-care-standard
• Australian Government. (2018). A Matter of Care: Australia’s Aged Care Workforce Strategy. Department of Health. https://www.health.gov.au/resources/publications/a-matter-of-care-australias-aged-care-workforce-strategy
• Australian Government. (2021). Mental health services in Australia. Australian Institute of Health and Welfare. https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/mental-health-impact-of-covid-19
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• Commonwealth of Australia. (2013). National Aboriginal and Torres Strait Islander Health Plan 2013-2023. Department of Health. https://www.health.gov.au/resources/publications/national-aboriginal-and-torres-strait-islander-health-plan-2013-2023
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• Schwartz, E. P. (2019). Educating the Nurse of the Future: Report of the Independent Review of Nursing Education. Commonwealth of Australia. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjIkcWkmMbzAhXb4zgGHSStCbQQFnoECAQQAQ&url=https%3A%2F%2Fwww.health.gov.au%2Fsites%2Fdefault%2Ffiles%2Fdocuments%2F2019%2F12%2Feducating-the-nurse-of-the-future.pdf&usg=AOvVaw0_gyV34h
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