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Through the use of reflective practice this essay identifies strategies to overcome challenges in regard to safe medication management, as I transition in to practice as a Graduate Nurse (GN). Strategies are discussed in association with governance and regulatory frameworks that encompass nursing as a self-regulated profession and are linked to the mutual experiences of other GN’s. Examples from personal experience placement (PEP) and relevant literature will provide supporting evidence to the success of the discussed strategies. Initially identifying challenges associated with safe medication management begins as a first year University student (Levett-Jones & Brourgeois 2011). Being fearful of changing situations as that of transition to practice and safe medication management is a normal human reaction amongst GN’s (Edwards et al 2015); (Spence Laschinger et al 2015). Safe medication management is the ultimate goal for all health care professionals (Lim & Honey 2015) and embraces standard four; Australian Commission on Safety and Quality in Health Care (ACSQHC), Medication Safety of the National Safety and Quality in Health Service Standards (NSQHSS) (ACSQHC 2012). The Australian Commission and Quality in Health Care designed ten set standards to provide a uniform set of measures of safety and quality for health care services (ACSQHC 2012). The ten standards are derived from evidence based improvement strategies (ACSQHC 2012). With an aim to protect the public from harm while improving the quality and delivery of health services (ACSQHC 2012). Utilising a framework such as NSQHSS by which to measure my own performance allows for self-governance (Chang & Daley 2012). Through maintaining and enhancing evidence base practice which underpins my nursing as a profession (Chang & Daley 2012). During my final placement at the Launceston General Hospital (LGH) Acute Medical Unit (AMU) the following challenges were identified. Above all else I fear being the GN that makes a preventable medication administration error. Medication errors associated with GN are linked with a lack of clinical experience and is noted to be a challenge of significant concern (Unver et al. 2012); (Saintings et al.). As inexperienced practitioners GN’s display a lack of confidence and competence in regard to the ability to think critically and work independently (Ostini & Bonner 2012); (Sahay et al. 2015). Therefore this could result in patient harm, leading to disciplinary action and de registration as a Registered Nurse (RN) (Atkins Britton & de Lacey 2011).
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Unsupervised medication delivery is also considered a significant challenge. As GN’s often have feelings of inadequacy and lack self-confidence surrounding unsupervised delivery of medications (Mellor & Gregoric 2016); (Edwards et al.2015). As a nursing student I have been directly supervised by a preceptor and practice under their nursing registration (NAMBA 2016). The preceptor is legally accountable for my administration of medications as a beginning level practitioner (NAMBA 2016). As a GN I will be independent and left to my own devices(NAMBA 2016). This is noted to lead to feelings of social isolation and disadvantage (Mellor & Gregoric 2016). Leading to heightened level of stress and anxiety associated with the delivery of safe medication management amongst GN’s (Mellor & Gregoric 2016). A lack of pharmaceutical knowledge is also identified as a challenge to GN’s (Saintings et al.). University provides GN’s with a base knowledge of pharmaceuticals on which to build upon (Lim & Honey 2014). The ability to link diagnosis with disease aetiology and medical intervention as a GN requires a sound evidence base (Lim & Honey 2015). Evidence based practice underpins nursing as a profession and for GN’s is built over time (Levett-Jones &Brourgeois 2011); (Chang & Daley 2012). Through the PEP experiences GN’s can endeavour to link clinical encounter with clinical experience, therefore building an evidence base (Levett-Jones &Brourgeois 2011); (Chang & Daley 2012). As I have matured and grown throughout my personal experience placements (PEP) so has my abilities and skill to reason; think, collect, interpret and infer and implement actions that foster safe medication management (Levett-Jones & Brourgeois 2011). I use reflection as a tool to provide insight and judgement on my own clinical performance to link and build my own evidence based practice (Wiles et al. 2013). There is a key relationship between the years of clinical experience, clinical decision making and safe medication management (Saintsing et al. 2011). There is an established link providing evidence that GN’s are prone to medication errors due to a lack of clinical experience (Unver et al. 2015). Critical thinking through the use of clinical reasoning is a major concept taught to undergraduate nurses at University (Levett-Jones 2013). Through the use of clinical reasoning I build upon my own competence and confidence as a strategy for error free medication management (Saintsing et al. 2011); (Wiles et al. 2013). Building a sound knowledge base surrounding pharmacology allows for a GN to question prescribers and potentially avoid any medication errors (Lim & Honey 2014) Therefore correlating to the Code of Ethics for Nurses in Australia value statement five; Nurses value informed decision making (NAMBA 2008). It also embraces clinical-governance through safe service delivery and links with the Code of Professional Conduct for Nurses (CPCN); conduct statement ten; Nurses practice nursing reflectively and ethically (NAMBA 2016). As a GN adherence to policies and procedure protocols on the PEP is a strategy vital to safe medication management (Armitage et al. 2007); (THO-North 2016). Knowing the location of policies and procedures and also having the pass words to electronic resources is valuable in the delivery of safe medication management (Armitage et al. 2007); (THO-North 2016). Seeking clarification of unknown medications from the on line monthly index of medical specialties (MIMS) is also a strategy to advances my medication knowledge (MIMS 2015). MIMS provides detailed descriptions on actions, contraindications and side effects of medications (MIMS 2015). It also shows I seek clarification on the unknown through self-directed learning to improve my evidence based practice (Chang & Daly 2012). The use of technology is reported to reduce the incidences of medication errors and evokes self-governance through education and professional development (Saintsing et al. 2011).Correctly identifying Pt’s by arm or leg band (Kelly et al. 2011) during clinical hand over is also a strategy to provide effective medication management (Edwards et al. 2015). Checking medication charts reveals any discrepancies in unsigned, non-administered, commenced or ceased medications (Kozier & Erb 2015). While embracing both NSQHSS standards five and six; Patient Identification and Procedure Matching and Clinical Handover (ACSQHC 2012).
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Checking patient identification against procedures encompasses the rights of medication administration (ACSQHC 2012); (Elliot & Liu 2010). Employing this strategy ensures health care consumer safety during the delivery of medications and is noted to reduce medication errors (ACSQHC 2012); (Elliot & Liu 2010). The rights of medication include; right patient, right dose, right drug, right time and right route (Harkanen et al.). Adherence to the rights of medication management is a proven strategy to provide a step by step checking process to reduce medication errors at separate intervals, during the process of medication delivery (Harkanen et al.) This also evokes clinical-governance through continuous monitoring of quality and safety to ensure health care risks are minimized (ACSQHC 2012). Questioning one’s peers during clinical handover can often seem like a daunting task as a GN (Chang & Daly 2012). However seeking initial clarification of unsigned for medications from the RN conducting hand over, embodies clinical-governance through continuity of person centred care across the continuum (Daley, Speedy & Jackson 2011). Furthermore as a GN delivering clinical handover to another RN with ISBAR as I have been doing on PEP in AMU embrace and promotes clinical-governance (Braine 2006); (Chang & Daley 2012). This is exhibited through the transfer of care, responsibility and accountability of a Pt on either a temporary or permanent basis to another member of the health care team (ACSQHC 2012). Planning and prioritising embodies shared-governance and is a vital key strategy in safe medication management (Unver et al. 2012). As a GN I need to prioritise my Pt’s and this is best done with a shift plan (Kozier & Erb 2015); (THO-North 2016), with a view of working smarter not harder (Belvins 2016). Therefore to achieve this goal I chose delegation for the administration of S4 and S8 medications to remain within my scope of practice (NAMBA 2016). Delegation reinforces shared-governance through team work, promoting safe effective medication management and client safety (Belvins 2016).Application for a transition to practice program is not mandatory (Edwards et al. 2015). However they are proven to increase both job satisfaction and retention rates of GN’s (Missen et al. 2014). Successful application would provide myself with support and further education through shared-governance (Ott & Ross 2014). With continual education and learning from experienced RN’s noted to be an effective strategy for preventing medication errors (Unver et al. 2012). With supportive environments through preceptorship, guidance and skill development noted to promote autonomy and empowerment of the GN through their transition to practice (Parker et al. 2014); (Kramer et al 2013). A transition to practice program is also proven to elevate stress and anxiety, associated with burnout and dropout rates in GN’s (Missen et al. 2014). Hence more GN’s continue nursing as a chosen career pathway (Missen et al. 2014). As nurses we practice under statutory and self-regulation (Atkins, Britton & DeLacey 2011). The Nursing and Midwifery Board of Australia (NAMBA 2016) regulates nurses and mid wives under the Health Practitioners Regulation National Law this is statutory regulation (NAMBA 2016). Statutory regulation depicts aspects of my professional practice that are set in legislation (Atkins, Britton & DeLacey 2011). These include title protection as a Registered Nurse, registration requirements and competence standards to enter practice (NAMBA 2016). Therefore successful registration with the Australian Health Practitioner Regulation Agency (ARPRA) would be evidence I have achieved a set standard for safe medication delivery and embrace the CPCN conduct statement one; Nurses practice and conduct themselves in accordance with laws relevant to the profession and practice of nursing (NAMBA 2016). Successful application also incorporates the notion of shared-governance and social contract in alliance with NSQHSS standard two; Partnering with Consumers (ACSQHC 2012). Self-regulation is my ability to adhere to the standards of practice as set out by the nursing profession its self (NAMBA 2016). This coincides with conduct statement two of the CPCN; Nurses practice in accordance with the standards of the profession and broader health system (NAMBA 2016). Both regulations described also encompass standard one; Governance and quality of service organisations (ACSQHC 2012). In conclusion a variety of strategies have been considered to overcome the identified challenges of medication management during the transition to practice as a GN. Evidence to support the strategies, as successful coping mechanisms is provided from the research literature. The evidence shows that all GN’s have similar fears surrounding the transition to practice involving safe medication management. The relevant frameworks and governance’s have been discussed in relation to strategies to show an understanding and an ability to practice nursing as a profession.Reference listAtkins, K, Britton, B & de Lacey, S 2011, Ethics and Law for Australian Nurses, Cambridge University Press, New York.Armitage, G, Manias, E, & Dunning, T 2007, 'Commentary on Manias E, Aitken R & Dunning T (2005) How graduate nurses use protocols to manage patients' medications. Journal of Clinical Nursing 14, 935-944', Journal of Clinical Nursing, vol. 16, no. 7, pp. 1382-1386. Available from: 10.1111/j.1365-2702.2007.01533.x. [14 August 2016].Australian Commission on Safety and Quality in Health Care (ACSQHC) 2012, ‘National Safety and Quality Health Service Standards’ Sydney, National Safety and Quality Health Service Standards, viewed 02 September, 2016<https://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-2012.pdf>Blevins, S 2016, 'Nurses as Educators. Foundation for New Graduate Nurse Success', MEDSURG Nursing, vol. 25, no. 3, pp. 194-201.
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Duke, M & Forbes, H 2012, ‘Dealing with the theory practice gap in clinical practices’, in E Chang & J Daly (eds), Transitions in nursing; preparing for professional practice, 3rd edn, Elsevier Australia, Chatswood NSW, pp. 271-288.Edwards, D, Hawker, C, Carrier, J, & Rees, C 2015, 'A systematic review of the effectiveness of strategies and interventions to improve the transition from student to newly qualified nurse', International Journal of Nursing Studies, vol. 52, no. 7, pp. 1254-1268. Elliott, M, & Liu, Y 2010, 'The nine rights of medication administration: an overview', British Journal of Nursing, vol. 19, no. 5, pp. 300-305, viewed 2 September 2016, via CINAHL (EBSCOhost).Härkänen, M, Ahonen, J, Kervinen, M, Turunen, H, & Vehviläinen-Julkunen, K 2015, 'The factors associated with medication errors in adult medical and surgical inpatients: a direct observation approach with medication record reviews', Scandinavian Journal of Caring Sciences, vol. 29, no. 2, pp. 297-306.Kelly, T, Roper, C, Elsom, S, & Gaskin, C 2011, 'Identifying the 'right patient': Nurse and consumer perspectives on verifying patient identity during medication administration', International Journal of Mental Health Nursing, vol. 20, no. 5, pp. 371-379.Kramer, M, Brewer, BB, & Maguire, P 2013, 'Impact of Healthy Work Environments on New Graduate Nurses’ Environmental Reality Shock', Western Journal of Nursing Research, vol. 35, no. 3, pp. 348-383. Available from: 10.1177/0193945911403939. [14 August 2016].
Parker, B, Kucia, AFedoruk, M, Laws, T, Philips, C 2012 ‘medications’, in Berman, A, Snydor, S, Kozier, B, Erb, G 2012, Fundamentals of nursing, Pearson Australia, Frenches Forest, NSW, pp. 900-975.Levett-Jones,T, 2013, Clinical Reasoning: learning to think like a nurse,1st edn, Pearson Australia, Frenches Forest, NSW.Levett-Jones,T & Brourgeois, S, 2011, The Clinical Placement: an essential guide for nursing student, 2nd edn, Elsevier, Chatswood, NSW. Lim, AG, & Honey, M 2014, 'New Zealand newly graduated nurses medication management: Results of a survey', Nurse Education in Practice, vol. 14, no. 6, pp. 660-665Mellor, P, & Gregoric, C 2016, 'Ways of Being: Preparing Nursing Students for Transition to Professional Practice', Journal of Continuing Education in Nursing, vol. 47, no. 7, pp. 330-340.MIMS 2015, About MIMS, MIMS Australia Pty Ltd, NSW, viewed 02 January 2016, <https://www.mims.com.au/index.php/about-mims/mims-australia>Missen, K, McKenna, L, & Beauchamp, A 2014, 'Satisfaction of newly graduated nurses enrolled in transition-to-practice programmes in their first year of employment: a systematic review', Journal of Advanced Nursing, vol. 70, no. 11, pp. 2419-2433, viewed 25 December 2015, CINAHL, EBSCOhost.Nursing and Midwife Board Australia (NMBA) 2008, ‘Code of Ethics for Nurses’. Melbourne, Nursing and Midwifery Board Australia, viewed 02 September, 2016, <https://www.nursingmidwiferyboard.gov.au/Codes-Guidlines-Staements/Codes-Guidlines.aspx>Nursing and Midwifery Board of Australia (NMBA) 2016, National competency standards for the registered nurse, NMBA, Melbourne, viewed 5 august 2016, <https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx#competencystandards> Ostini, F, & Bonner, A 2012, 'Australian new graduate experiences during their transition program in a rural/regional acute care setting', Contemporary Nurse: A Journal For The Australian Nursing Profession, 41, 2, pp. 242-252, viewed 25 December 2015, CINAHL, EBSCOhost.Ott, J, & Ross, C 2014, 'The journey toward shared governance: the lived experience of nurse managers and staff nurses', Journal of Nursing Management, vol. 22, no. 6, pp. 761-768.Parker, V, Giles, M, Lantry, G, & McMillan, M 2014, 'New graduate nurses' experiences in their first year of practice',Nurse Education Today, vol. 34, no. 1, pp. 150-156, viewed 27 August 2016, via CINAHL (EBSCOhost).Saintsing, D, Gibson, L, & Pennington, A 2011, 'The novice nurse and clinical decision-making: how to avoid errors', Journal Of Nursing Management, 19, 3, pp. 354-359, CINAHL Complete, EBSCOhost, viewed 14 August 2016.
Sahay, A, Hutchinson, M, & East, L 2015, 'Exploring the influence of workplace supports and relationships on safe medication practice: A pilot study of Australian graduate nurses', Nurse Education Today, vol. 35, no. 5, pp. e21-6, viewed 28 August 2016, via CINAHL (EBSCOhost).
Spence Laschinger, HK, Borgogni, L, Consiglio, C, & Read, E 2015, 'The effects of authentic leadership, six areas of worklife, and occupational coping self-efficacy on new graduate nurses' burnout and mental health: A cross-sectional study', International Journal of Nursing Studies, vol. 52, no. 6, pp. 1080-1089. Available from: 10.1016/j.ijnurstu.2015.03.002. [14 August 2016].
Tasmanian Health Services (THO-North 2016), ’Acute Medical Unit, Orientation Package’, Launceston General Hospital, Department of Medicine – Acute Care Services, Launceston, Tasmania, 2016.Unver, V, Tastan, S, & Akbayrak, N 2012, 'Medication errors: Perspectives of newly graduated and experienced nurses', International Journal of Nursing Practice, vol. 18, no. 4.Wiles, L, Simko, L & Schoessler, M 2013, “What do I do now?; Clinical decision making by new graduates’, Journal for Nurses in Professional Development, vol. 29, no. 4, pp. 167-172, viewed 3 September 2016, via MyLO.
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