In this reflective piece, our nursing colleague, Anna Ballantyne shares her experience of some practices and strategies that help to sustain her through her most testing ED shifts. She describes the challenges faced in contexts such as triage, time-pressured work-ups and flow, and gives some helpful tips on maintaining an even keel when things get chaotic.
I need a goat stat… and other emergency nursing woes.
Purportedly, goats keep racing thoroughbreds calm and settled. Taking a goat from a horse’s stable serves the ill-purposed intent of upsetting, unsettling and thereby ruining said horse’s chance of winning an upcoming race. In the spirit of evidence based practice, please note that this explanation has the expert consensus level of ‘urban legend’.
So, what’s got your goat, emergency nurse (or any clinician)? And how do we get it back?
Emergency nursing is an art. This includes astute observational skills, instant rapport building capacity, grace-under-fire demeanour, ready-to-act and usually a cheeky glint in the eyes. Emergency nurses work hard to increase their knowledge and skill base. There are many times the experience and knowledge goes untapped, stopped in the stall. Containing all this with no outlet can be challenging. Simply being listened to will open the gate to collaborative, enhanced patient care – this goes in all directions, to all members of the multidisciplinary team and makes for happy, engaged, on-the-same-page team members. Emergency departments have come a long way in this respect and this is to be applauded. It is also a continuing journey.
To call out one of the elephants in our proverbial zoo… The National Emergency Access Target (NEAT) is an evidenced based patient safety practice, and it has made the emergency nursing workload rise exponentially. It feels like the moment you approach completion of the necessary work-up at high speed, your patient gets moved and you start from scratch with the next one. No longer is there someone completely worked up, stable and waiting. It’s a perplexing “reward” for a job well done!
Additionally, access block, lack of “no vacancy” signs on the front door, and demand for flow (when you have just graciously accepted three undifferentiated new patients with a smile) – these ice the NEAT cake. Emergency nurses are often the middle-men and interpreters between teams, units, staff and families, and that can be a demanding and noisy challenge. Goat now please!
What does the goat look like?
It looks like inpatient beds, friendly reception, and clear plans formulated early so we can pre-empt the ‘bed ready’ with ‘all done’. If we are asking for a plan, the intent is not to steal the goat of the plan makers; rather it is to keep both of us in the race. Other options are to:
A) Ask for help or to ask which of these priorities is the priority?
B) Professionally challenge rude behaviour – report if necessary, and model a good response.
D) Eat the elephant one bite at a time.
If you are overwhelmed; first, just breathe – step somewhere quiet, take 3 – 5 deep breaths: don’t think; just breathe; then go back to point A. Please know that there is not a single other person in the ED who doesn’t identify with you and also know that you do get better at responding to the chaos.
Triage is for the Phar Lap of racers – you need (physiological and emotional) cardiomegaly to survive this one. Studies have shown that ED triage staff experience the highest rate of occupational violence (OV) in ED[1]. Please see your OV Prevention team for reporting, education and support – it is not ok. Everyone has the right to be safe. Triage often has the lowest nurse to patient ratio. At times, it feels like you get pushback from every single area in ED – but the (sour) cherry on top is others making a judgement call on the ATS score that has been prescribed.
Goat! Goat! I need a goat! (I need a few).
Firstly, I need support, respect and trust – trust that I provide a high level of sift-and-sort skill. Also, though I am open to learning, please use the right channels to feed back to me unless it is time critical. I check the outcomes to assess my proficiency regularly. I am the one who is looking at the patient and may see what cannot be seen from a computer screen.
It is worth noting that Emergency Nursing has the most progression phases within nursing specialties – meaning that they are a skilled bunch, but it takes longer to gain seniority. The progression phases are seen as competitive by some. Remember that the goal is exceptional patient care. None of us walk in the same shoes. We don’t know everyone’s story or the multiple factors that impact their journey. Encouraging the best in all runners, speaking well of team mates and focussing on our own journey rather than others will keep the lanes clear.
From a team perspective, I think the most challenging aspect has to be losing a colleague along the track. Choice is one thing – a runner resigns or moves on; this can be happy-sad. Intentional harm is the worst – gossip, lies, bullying and harassment – I don’t know if a flock of goats can fix that. I remember a comment from a colleague about looking forward to ‘toppling the next’ teammate – it shook me because they did it, unjustifiably. You see, the race is hard enough. Sometimes we forget that our words and actions impact more than ourselves or even their intended audience: simply knowing this behaviour exists breaks trust and steals the safety from every other team member. Not one of us lives or acts without affecting another human being.
Conversely, there are many, many team members from varied disciplines who are the calm in the storm. I am thankful to be surrounded by integrity, support, wisdom, grace, skill, intelligence, kindness, hard workers, teammates with shared vision, trust and respect. If good actions (behaviour) are applied appropriately through various situations, done for appropriate reasons (e.g. values based, not for egotistical purposes) it creates a pattern of stable moral virtues[2]. These people are not perfect but they consistently soothe their team and lead by example (no matter what their role), the result of which is unified vision and better patient care.
Which brings me to the thankfulness goat – it works both internally and externally, spreading hope and perspective. Thankfulness-coloured glasses help with life, and we can choose to wear them.
We all have different roles, experiences and pressures. We can and need to take healthy life approaches to wellness. However, wellness cannot be achieved by external actions alone. It needs internal values and life alignment (behaviour). Virtuous character is the most effective goat of all.
[1] Morphet Julia, Griffiths Debra, Plummer Virginia, Innes Kelli, Fairhall Robyn, Beattie Jill (2014) At the crossroads of violence and aggression in the emergency department: perspectives of Australian emergency nurses. Australian Health Review 38, 194-201. https://doi.org/10.1071/AH13189
[2] Bradford Cokelet, Ph.D., What Does It Take to Have Good Character? (n.d.). Retrieved from https://www.psychologytoday.com/au/blog/questions-character/201901/what-does-it-take-have-good-character
WRaP EM 
This is really spot on, good (or bad??) to know that our ED in SA is experiencing the same things as everyone else!!
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