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   Last modified: June 6, 2005

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A lifelong commitment to learning

Claudette Drapeau (left), an RPN with 27 years’ experience, and Lisa Rocca, RPN, a new member of the profession, are true believers in the importance of preceptoring.

Photo: M. Gordon

How nurses support their colleagues as they make the transition from learner to expert plays a key role in retaining nurses and ensuring the public receives safe, effective and ethical nursing care.

When Lisa Rocca graduated from the nursing program at Lambton College in June 2004, she felt that she was prepared, academically at least, to start her career as an RPN. "The school taught us well," says Rocca, who landed a job with Bluewater Health in Sarnia, working in complex continuing care, and now also in in-patient psychiatry. But she quickly realized that her education was just beginning. "The reality of being on my own was a bit frightening," says Rocca. "Within my first week, I had to prepare a body for the morgue. I thought, 'I don't remember this from class.' It was just overwhelming. I look at school now as just the baseline, the stepping-stone into my career. When you start work, you're still learning. Your program may be done, but your education isn't. "Gaining the education, experience and confidence to move from a novice to an expert is a challenge in any career, but it is absolutely critical in a fast-paced and constantly changing field like nursing. The public trusts that regulated health professionals like nurses are competent to provide safe, effective and ethical care at any stage of their careers.

Recent changes to RN and RPN education requirements, which increased the length of time students study, is one way the College helps nurses to gain experience and confidence in today's demanding environment. In this issue of The Standard, the College launches a new guideline, Supporting Learners, to provide nurses with important information about the expectations and professional responsibilities when working with learners.

"How nurses support their colleagues as they make the transition from novice to expert plays a key role in ensuring the public receives safe, effective and ethical nursing care," says Lisa Valentine, a Practice Consultant at the College who led the revision of Supporting Learners. "It can take nurses up to a year to gain the confidence they need to make sound, independent decisions in a new environment."

"As self-regulated professionals, nurses have a professional responsibility to support learners," says Michelle Cyr, a Practice Consultant at the College and contributor on the same guideline.

"This support can be provided formally, as preceptors and mentors, and informally, as members of the team who share their expertise and experience. Either way, the goal is to facilitate the success of individual nurses, and ensure that the public receives safe, effective and ethical care. "Learning isn't just a challenge for nurses who are entering the profession. Nurses who are new to practice in Ontario, or nurses who took time off to raise a family and then return to practice, or experienced nurses who take on new roles, can suddenly find themselves facing another learning curve.

"It was stressful becoming a novice again," says Kathy Loree, an RN who spent 24 years on a surgical ward at St. Mary's General Hospital in Kitchener, before taking a new position last year in the ICU/CCU. "But learning and change are good. It's how you grow as a person, as well as a professional.

If you aren't challenged, you can become stale. And when you forget what it's like to be learning, you can't help other learners. "How do any nurses, at any point in their career, become more expert? What fears do they face? How do they overcome them? What role do more seasoned colleagues play in grooming the next generation of experts? And what does the word 'expert' even mean? Claudette Drapeau, who works in the rehab unit of Blue water Health, has been an RPN for 27 years. She often acts as a preceptor for nursing students. She works with them side-by-side for two months, letting the students shadow her at first, and then shadowing them. "We start to cut the tether, but if they have any doubts about anything, they can come to me," she says.

When nurses make an error in judgment or perform a procedure incorrectly, the results can be devastating for clients. As regulated health professionals, nurses are expected to anticipate when errors are more likely to occur and take action to lower the risk to clients. This is particularly true when it comes to supporting learners. The preceptor catches mistakes or misjudgements before they happen, as Drapeau did once when she noticed that her student was about to administer a medication to the wrong client. “I asked her if she was going to check the client’s armband. I thought this would give her the chance to seethe possibility of her mistake,” recalls Drapeau.

"The student said, 'No, I was going to give it to Mrs. Smith in D Bed.' That's when I told her that Mrs. Smith was in A Bed. I reminded her of the importance of checking an armband and applying the five 'rights' for medication administration - right medication, right client, right time, right dose, right route."

By the end of their time with her, Drapeau wants her students to take pride in, and be accountable for, their work, and to put the client first.

Rocca says she can’t imagine what the transition to practice would have been like without her preceptor, and other more-experienced colleagues showing her the ropes. “Knowing that there’s someone looking over your shoulder is comforting,” says Rocca. “For something like administering medication, when I was in school, I had one client and a teacher by my side. She would do it with meat first, ask me my comfort level; then when I was ready to do it on my own, she would shadow me.”

You learn as you go, Rocca says, until you get to the point, in "the real world," where you can confidently give meds to half a unit. As a novice nurse, she also knows that you can't be afraid to ask questions, even if you think you should know the answer. "There's always someone else thinking of the same question," she says, "and I can go to anybody on the floor for help."

The technical aspects of nursing - things like medication administration, dressings and wound care, and catheterizations - have come quickly for Rocca. What’s harder is developing a rapport with her clients on the inpatient psychiatric unit. She's getting better at it, she says, but it's still a learning process.

Drapeau says that preceptors like her can be particularly helpful in modelling the ability to establish a therapeutic relationship, which includes demonstrating a caring, supportive and empathic attitude to clients. "The tendency sometimes is to be detached," says Drapeau. "Sometimes, students are afraid to touch a client. I encourage them to hold their hands, laugh with them, cry with them, and not be afraid to feel. If they can do that, they'll love their job."

CNO's Cyr notes that the formal orientation for any learners - whether they're new to the profession, new to Ontario, or new to a practice setting - is usually quite short. But if it takes up to a year to build learner confidence, she/he will need the support of team members well past the end of their orientation.

"More experienced nurses need to recognize this learning curve and provide ongoing support when their colleague needs it," says Cyr. "I've spoken to nurses who were terminated from their job, shortly after their orientation, and while there are often a number of contributing factors, the nurses often say that they received little or no support from their colleagues. They felt like they were thrown in the deep end."

No nurse should ever have to experience such lack of support, says Denise Button, RN, an acute care nurse practitioner/team leader at the Heart Function Clinic, Trillium Health Centre, Queensway Site in Toronto.

Button is a preceptor for third-year, Masters' and ACNP students, and says she always tries to be approachable. "I tell students right away that every question is valid. It’s a very open environment. If you don't have that, people won't ask questions, and the outcome for the client may not be as positive as it could have been. This also increases the risk of the client being exposed to an unsafe situation,” she says. "You must have a positive nurturing environment for the transfer of knowledge to occur."

The Ministry of Health and Long-Term Care (MOHLTC) recognizes the value of having a support system in place for nurses. Last year, they announced a $29.1 million investment in a comprehensive nursing strategy. It provides funding to nursing schools, hospitals, public health units, home health agencies and long-term care facilities to support nurses throughout their careers. In some cases, the MOHLTC funding has enabled employers to offer new graduates extensive internships that go well beyond standard orientation.

These internships prepare novice nurses for work in specialized and high need areas, such as critical care, inner-city health and mental health. Some employers are using the money to develop preceptorship and mentorship programs to help nurses in new roles, nursing students and recent graduates make the transition to practice. Others are using the funds to help expert nurses develop the competencies to become preceptors and mentors.

According to Sherri Huckstep, manager of the Nursing Secretariat, having mentors and preceptors in place not only supports nursing practice and improves the overall quality of nursing work, it subsequently improves nurse recruitment and retention.

"We'll continue to explore ways to help employers and nurses create professional practice environments that will support nurses as they move from novice to expert practitioners," says Huckstep.

"There's an increased expectation these days for nurses to hit the ground running," says Kathie Conlin-Saind on, the Education Consultant with the CNO. "But you can’t put undue pressure on yourself or rush the process. Sometimes, acquiring expertise comes with an 'a-ha!' moment of realization. But mostly, it's a gradual process."

Her best advice is simply to make a commitment to lifelong learning, whether formally, from your peers or from your clients. "If you don't continue to learn," says Conlin-Saindon, "what you know will be old really fast."

She remembers well her own early days in the profession, working one night at a nursing home, the sole RN in the building. "I had experienced colleagues there, but I suddenly realized, I'm the only RN here - I can’t get an RN, I am the RN! You just have to pull up your bootstraps and rely on your knowledge and judgment." The feeling of security in your practice can be fleeting, lasting only until the next new challenge, the next client who’s presenting with something you've never seen before or your next new practice setting.

That's certainly true for Loree's move to the ICU/CCU at St. Mary's General Hospital. One of the hardest adjustments was her inability to always operate on instinct. Over her career, Loree had built up a body of knowledge and experience that allowed her to size up a situation quickly and act. She was one of the nurses colleagues would turn to for advice. In the ICU/CCU, Loree felt frustrated at not having all the answers. But she was never hesitant to ask questions.

"I had the benefit of an excellent preceptor, who explained the rationale for procedures and treatments and gave me lots of hands-on things to do," says Loree. "When I can see the how, why, when and where of something, it quickly becomes second nature. I find that I learn better that way than from a book. I also learned a lot from asking different things of different nurses, because each nurse has some area of expertise."

Comfort with the day-to-day responsibilities - the ward routine, documenting assessments and the like - came relatively quickly. What has taken longer is getting used to clients with a higher level of acuity, and to "the unexpected," she says. Just recently, she saw a ventilated client's heart rate spiralling downward to the 30s, and then to 29.

"My first instinct wouldn't have been to suction his airway or 'bag' him," says Loree. "The nurse who responded with me explained that if his airway is obstructed, the heart slows because of increased pressure. By hearing her explain what was happening and watching her take action, I won't forget how to handle this if it happens again. Very few people will ever learn everything about nursing. There's always something new."

For any nurse, becoming an expert is a journey, not a destination. You have to upgrade yourself continually, and keep up with guidelines and best practices to maintain the safest quality of care, says Button, "It never stops.” Just as learning must be lifelong, so must be supporting other learners, as Rocca has discovered. After practicing for almost a year, she's much more comfortable and confident as an RPN.

A few months ago, she was assigned some new RPN students to shadow her. “It was intimidating to think that I was already looking after students when I was just one myself," she says. "But when they were asking me questions, I did have the answers. I could see my own progression."

While she has become more knowledgeable, Rocca also realizes that she'll never know it all. ”It’s almost unrealistic to use the word 'expert,'" says Rocca. "I would use 'experienced.' Some people become more educated in certain areas, but you'll never come to the point where you say, 'That's it, I'm done learning.'"

Next — Feature - New guide for helping learners

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