Jun 14, 2021, By: Jeshna Kumari
The correct use of personal protective equipment (PPE) and medical equipment is crucial for effective patient care and infection prevention and control. It is a cornerstone of nursing practice. PPE is a health-care measure used to reduce exposure to infectious diseases. However, when I first began my clinical practicum at an acute care hospital, I noticed many discrepancies between best practice and the reality of PPE and medical equipment use among nurses. In this article, I describe the events that I observed on the first day of my practicum at an acute care hospital. Subsequently, I discuss the factors contributing to these events and reflect on the lessons learned.
A startling series of events
On the first day of the practicum, I was tasked with shadowing a nurse. In doing so, I observed practices that alarmed me. We began the day with taking vital signs, and the nurse did not clean her equipment before, between, or after her patients. This was confusing for me as the first step students learn is to sanitize equipment before beginning a procedure, between patients, and after the completion of a procedure. When I observed the omission of this practice, I asked myself, “Does the nurse know that she needs to clean this equipment?” “Is she aware that she is not cleaning this equipment but continuing to use it anyway?” “Does this practice normally take place, or is this just an occurrence today?” and “Does the nurse understand the negative outcomes this practice can have on patient health?”
This was an uncomfortable experience for me as I felt that the nurse put other patients and individuals at risk of contracting MRSA.
As the day continued, I also observed the nurse incorrectly wear PPE. While preparing to go into an isolation room with a patient who had methicillin-resistant Staphylococcus aureus (MRSA), the nurse did not tie the bottom string of her gown. The best practice guideline for donning PPE includes firmly tying both the neck and waist strings of a gown, after which, it is also important to ensure that the front and back of the body are covered by the gown. Unfortunately, the nurse did not comply with this practice and entered the patient’s room. Upon entering, the nurse took the patient’s vital signs, leaned against the bed to talk to the patient’s family and swiftly walked around the room with a flailing gown. As a result of this, the underside of the nurse’s gown touched the patient’s bed, table and clothing. The back of the nurse’s scrubs also came in direct contact with the patient’s environment. When the nurse came out of the room, she quickly doffed her PPE, did not clean her medical equipment and went on to care for the next patient. Although the nurse’s clothing was potentially contaminated, she also proceeded to sit on chairs around the unit and on other patient’s beds, and she wore her scrubs home. This was an uncomfortable experience for me as I felt that the nurse put other patients and individuals at risk of contracting MRSA
Amid these events, another nurse also stated to me, “Do as we say, not as we do.” I was shocked by this and asked myself, “Why are these nurses acting in ways they know are incorrect?” Given these questions, I began analyzing the context of the events to better understand why these actions took place.
Reflecting on the factors contributing to the events
With the complexity and fast-paced nature of nursing, the correct use of equipment can be difficult to implement due to personal barriers, changing circumstances and decreased time. For example, during the first few hours of shadowing the nurse, she provided me with information about the unit and patient medications. During this time, she was serving both the role of a nurse and the role of an instructor. Although this was valuable to me, limited time remained for her to take vital signs, do assessments and administer medications. As a result, she became disorganized, began doing her tasks quickly and rushed in and out of patient rooms. In the hurry of meeting patients’ demands, the nurse could have forgotten to use the equipment correctly or perceived that she did not have adequate time to do so. As well, it was the nurse’s first time having a student shadow her. This new experience could have been overwhelming as there was already limited time to provide patient care, especially as I was shadowing her the entire shift.
In addition, the unit on this day was at maximum capacity. The nurse was assigned to six patients, in contrast to her normal assignment of five patients. As such, she already had limited time due to an increased workload. In recognizing this lack of time, she prioritized the administration of patient medications, which could have resulted in less attention toward the correct use of PPE.
Given the many contributing factors, I learned that nurses are heavily engaged in tasks oriented toward direct patient care, such as medication administration and unit responsibilities. However, these tasks can serve as barriers to implementing adequate infection prevention and control measures, such as correctly wearing PPE and cleaning medical equipment.
- Leaders are crucial to enacting change: At first, I felt that I was at a loss because I was not being adequately guided to follow evidence-based practice, as I had been taught in my nursing education. However, with further reflection, I gained a key insight. I learned that the degree to which nurses implement leadership into their care impacts how they conduct patient care and are able to implement infection prevention and control measures. As such, I recognized that change must begin with individual leaders transforming the culture and expectations of the unit so that existing practices can be reconstructed.
- Nursing students can lead by example: This insight has impacted my learning as a student as I have become conscious of my actions and have chosen to lead by example. I have discovered my responsibility to advocate for an environment that reduces the risk of infection transmission. For example, I discussed the inadequate use of PPE with my nursing instructor and the unit manager and wrote a report that provided information about the situation and offered a subsequent plan of action. As well, in recognizing that the unit culture influences the day-to-day care of patients, I discussed nurses’ expectations and workload with the unit manager to better understand how the unit culture contributes to staff implementing such measures. My decision to lead by example began to change the dynamics of the unit, as the health-care team observed a student’s commitment to upholding infection prevention and control measures.
- Nurses must effectively manage their time: As a student, I have also been enlightened to the relationship between nursing practice and time. This relationship guides the profession as nursing care is highly sensitive to time constraints. As front-line providers of care, nurses must learn to manage their time effectively and delegate within that time to support the needs of their patients and fellow nurses. On the day with the nurse, the relationship to time had been disturbed by multiple circumstances, leading to suboptimal practices. As such, it is critical for me as a student to learn to be adaptable and effectively cope with stress so that I can respond to changing circumstances in a timely and composed manner.
- Nurses should engage in self-care to enhance their practice: I believe that meditation is an important and effective tool that allows me to stay grounded during stressful situations and helps me become aware of my actions. As such, I am able to quickly adapt to changing circumstances, thus significantly influencing the quality of the patient care that I provide. Therefore, I will continue to engage in 20-minute meditation sessions three times a week, increasing this as my schedule permits. I will also aim to provide knowledge on my experience with meditation to the interprofessional team. In doing so, I will not only enhance my ability to manage time through developing effective coping skills and learning to be adaptable but will also guide others to do the same.
Although disappointing at first, my first day of shadowing a nurse at an acute care hospital was a blessing in disguise as I learned some key lessons that are foundational to nursing care. I am also grateful to have had the opportunity to reflect on these events and will continue to be an agent for change within the profession.
Jeshna Kumari is a third-year bachelor of nursing student at the University of Calgary. Jeshna currently engages in a variety of volunteer and leadership roles at her university, local hospital, and in local and international communities. Jeshna also conducts research in child and family health at the Healthy Families Lab in Calgary, Alberta, and is passionate about advocating for these patient populations in the health-care system.