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Meet Angelica, a Respiratory Nurse Consultant (CNC) from Westmead Hospital.
Tell us about yourself
Hi, I am Angelica Bariuan, a Clinical Nurse Consultant (CNC) on a Respiratory ward. My interest in joining the healthcare sector originated from observing my mother perform her role as a Registered Nurse in a little town located in the Philippines, where she would assist patients in a hospital-in-the-home setting. After finishing my high school certificate in the Philippines, my mother assisted me in applying to the University of Wollongong where I studied a Bachelor of Nursing and graduated in 2014. I started my career through a Transition to Professional Practice (TPP) program,
What does your role involve?
My hospital previously did not have a Respiratory CNE, I was involved in projects and initiatives that naturally, a CNC role would perform. The role is guided by five (5) different domains, including clinical consultancy, leadership, education and training, research and clinical service planning.
For example, clinical consultancy where I am involved in assisting the respiratory team and multidisciplinary healthcare team to develop a management and/or discharge plan for patients with exacerbation of their diseases and those who required non-invasive ventilation therapy and assist in transitioning these patients home as required. Furthermore, I am involved in reviewing our models of care and service delivery, as well as developing and reviewing essential documents, including the policies and guidelines which direct our respiratory nursing practice.
My typical day as a Respiratory CNC varies every day however, I can describe it with one word, BUSY! As I was establishing the CNC role, my day mainly includes reviewing high acuity patients on high flow oxygen therapy and non-invasive therapy and underwater seal drains with the medical team, developing and reviewing clinical business rules and clinical processes, attending meetings such as multidisciplinary team meetings, stream and committee meetings.
I was surprised at how autonomous my role is, as I was not used to consulting patients without the medical team at times and maintaining a collaborative relationship. However, I embraced the role and have given my hardest to transition, which I was told that I have achieved.
Common respiratory nursing presentations?
The top 3 respiratory presentations that I often see are type 1 or 2 respiratory failure, exacerbation of asthma/COPD, pulmonary embolism and pleural effusion. My role is to ensure that the nursing staff are aware of important aspects in patient care for their admitting reason and that they are aware of management plans and competent in certain procedures such as NIV/HFNP. For example, management of respiratory failure patients and what to look out for such as ABG, respiratory assessments and if they are on ventilatory support.
Another would be for pleural effusions, ensure that nurses are aware of different management options such as chest drain management. I assist in developing and coordinating plans such as through respiratory failure and drain rounds. For patients with exacerbation of their asthma/COPD, I ensure that patients have an adequate understanding of their disease and their management such as through inhaler education/ action plan, promoting smoking cessation and linking patients up to community services.
Common medications used in respiratory nursing?
The most common medications we use are inhaler medications and prednisone tablets. Inhaler technique assessment is a skill that isn’t done very well or is often missed when patients are admitted with an exacerbation of asthma/COPD. One aspect of my role is to ensure that staff receive adequate education and are confident in providing education to patients to ensure effective medication administration with inhalers.
Concepts nurses struggle with (junior or senior) about respiratory nursing?
I guess in general it’s very individualised. I realise that everyone tends to forget even the basics such as conducting a comprehensive respiratory assessment or even a patient assessment. Most especially when the clinical load is heavy, patients are more acute and staff are not as experienced. I found that everyone understands the basic respiratory physiology such as around gas exchange.
However, once I try and target specific topics such as asthma, COPD, pulmonary fibrosis or respiratory failure and management therapies, this is when things become a bit complicated. Staff could assess when patients are unwell however, patient management from nurses I thought could be improved. More specifically, around making sure they understand why certain therapies such as inhalers, steroids, bilevel/cpap home therapy are important and encouraging and advocating for their patient’s compliance.
As an educator, I believe that knowledge is power as it enables staff to provide better care to their patients. And what made it more challenging was recognising that each staff had a different way of learning so you have to be creative, so I did everything making sure I target all adult learning principles, from doing presentations, practical teaching and patient bedside supervision. Teaching is hard but effective teaching is harder. Making sure that what you are teaching is absorbed and can be applied in practice makes a huge difference to patient care experience and outcomes.
It was challenging in the beginning as there was not a structured education program when I started in this CNC role, and we had very junior staff members at the same time. The materials I developed like workbooks and presentation slides to educate staff was made in collaboration with our multidisciplinary team to draw from the perspectives of the medical and allied health teams. I always make sure that when I deliver education to either junior or senior staff, I start with a quick recap of the basics to make sure I have everyone’s attention, we are all on the same page, and I have an engaged audience ready to participate and contribute to the education session.
Tell us about a piece of equipment in respiratory nursing!
Inhaler devices – there are so many types of inhaler devices and each has a different way of using it. According to the National Asthma Council, 90% of Australians are not able to use their inhaler devices correctly, and if your patient has a respiratory disease, the chances of them having an inhaler device is very high.
But, being able to use it appropriately is important. There is a big emphasis on ensuring inhaler technique assessment and education of patients happens regularly. This is also the same for health professionals, everyone has a responsibility to make sure that our patients are using them right as this helps patient manage their chronic symptoms and exacerbations.
What is one thing you wish you would have known before you started in respiratory nursing?
I wish I had a structured foundation program to assist in my transition to respiratory nursing from general ward nursing. It would’ve helped to have guided education and a training program that focused on the basic respiratory nursing topics and skills. Connecting with existing support groups such as the Respiratory Nurse’s Interest Group (RNIG) was helpful as it allowed me to network with other respiratory clinicians and gain knowledge on different respiratory diseases and management plans, whilst keeping up-to-date with current evidence-based practice and what other areas are doing.
Why should other nurses or students consider respiratory nursing?
I found that the respiratory clinical field is fun yet challenging. I have learnt so much and helped others learn and love this speciality area too. It really is up to the individual clinician as everyone will find their clinical field of choice. You see respiratory symptoms everywhere, most especially breathlessness/dyspnoea, it sounds so simple but it affects our patients holistically and it limits the way they get to live their life.
For me, it was about helping my patients survive and breathe better. It was when I looked after respiratory failure patients and help them recover and get out of the hospital without being intubated, improve their breathlessness and have a better quality of life, I feel satisfied. Being in this field allowed me to think critically about my patients and what I can do to help them get better.
How has COVID-19 impacted you and your colleagues?
COVID-19 has definitely affected the healthcare system in a way that clinicians had to immediately adapt to the rapid changing clinical environment and be able to develop and implement models of care and processes to ensure patients affected by COVID-19 still receive best possible care whilst ensuring the safety of all those involved.
We transitioned to be the COVID-19 ward and facilitated rapid upskilling of staff to ensure we are able to manage high-acuity patients, including those who may require arterial lines and/or inotropes. Furthermore, I was able to become part of COVID Response Team. It was a challenging time for my colleagues however, as a team we were able to get through it all and became stronger as a team.
What is the Respiratory Nurse’s Interest Group? ?
The Respiratory Nurse’s Interest Group (RNIG) of NSW is a state-wide not for profit organisation that aims to provide a forum for respiratory clinicians that includes medical, nursing and allied health team members to promote further learning on the management of respiratory conditions. We organise and conduct our own educational events, including evening seminars and study days on various topics throughout the year for members, as well as partnering with and promoting upcoming events within the respiratory community.
RNIG provides an amazing networking opportunity for respiratory clinicians to meet other clinicians from other health services within the state to share our knowledge and current practices. I am the Webmaster who is responsible for website updates and the management of our social medica pages such as our Facebook Group.
What is clinical leadership and why is it so important?
Clinical leadership to me is having the ability to influence my colleagues, develop and implement quality improvement projects and improving them through the process of practice change. I have been involved in a few quality improvement projects that are not all respiratory specific skills but are rather general nursing care focused. For example, QI around bedside clinical handover, pressure injury prevention and management, inhaler education and pleural procedure kits.
Why is high-quality nursing education important to you?
High-quality nursing education is important to me because I believe “knowledge is power”. I have previously observed how lack of education and insufficient clinician knowledge can lead to poor nursing practice that increases the risk of patient harm. I believe that education empowers clinicians to deliver high-quality, safe and evidence-based care.
In addition, this assists in identifying aspects of clinical practice and within their clinical area that requires improvement that hopefully leads to change or improvement in practice. I believe in the importance of reinforcing nursing education even after our new nurses have completed their bachelor’s degree.
What advice do you have for new nurses entering the profession?
I have 2 things. Firstly: keep learning and never stop trying to improve your nursing practice. Put your hand up to do things even if it’s as simple as a quality improvement project. If you see something that can be improved, do something about it.
Second, don’t be afraid to admit that you do not know something and don’t hesitate to ask for help. I have seen this in the field a lot of times where staff are not saying anything but it’s obvious. I have always assisted in promoting psychological safety where everyone should have a safe space to express their thoughts and discuss and manage professionally. For example, discussing clinical incidents and working together to manage or mitigate risks, is about advocating for patient and staff safety and wellbeing.
What’s some of the lessons you’ve learnt in your journey so far?
I always get told I am so young, and I wonder if I am young to do what I am doing, being 26 years of age and 6years of nursing experience under my belt. Some of the lessons I have learnt along my journey are first, you are never too young or too old to do anything. If you have a passion for something, then try your very best to achieve it. Second, it’s okay to say you don’t know, we learn something new every day, every time! The field of health is continuously growing and our practices are continuously changing.
Where should people get more information about respiratory nursing if they are interested?
Please visit the RNIG website, http://www.rnig.org.au/ and flick us your question if any!
Other great websites for anyone interested in respiratory nursing include:
The Lung Foundation https://lungfoundation.com.au/,
The National Asthma Council: https://www.nationalasthma.org.au/
The Thoracic Society of Australia and New Zealand: https://www.thoracic.org.au/