By Rose O. Sherman, EdD, RN, NEA-BC, FAAN
Since the challenges with the Apollo 13 spaceflight in 1970, the term – Houston, we have a problem – has become a popular phrase to call attention to a new and unforeseen problem of significant magnitude. Seasoned nurse leaders across the country may be using it today in their leadership meetings as they come to grips with cracks in the foundation of nursing practice in their organizations after a turbulent two years. One leader recently shared the following story that I have heard many variations of during the last 4-6 months:
I have managed this unit for five years and continue to struggle to hold things together, but honestly, I see things that I have not contended with before. Over the past three weeks, two patients have developed pressure ulcers on my unit. As I began investigating, I learned that turning patients was no longer routine, nor were skin assessments or pictures of skin breakdown. My staff told me that they did not have time to do it during COVID and now because of short staffing. I thought back and realized that the skincare champion on our unit retired five months ago, and no one volunteered to do it after she left. She was relentless in monitoring our patients – the staff called her the skincare Taliban. As I looked around the safety huddle I was conducting; I realized that 2/3 of my nurses have less than three years of experience. Many went to school remotely and came into practice during COVID. They were never oriented to basic nursing care and are not doing it now. Many unsafe practices occur, and no experienced or seasoned nurses are there to correct our newbies.
This nurse leader is not alone in finding that when she stops for a moment from fighting the fires of staffing and scheduling, she learns basic policies and practices are not followed. It is a classic example of the normalization of deviance – a growing challenge in many organizations and a major safety issue. The normalization of deviance can be defined as a gradual process in which unacceptable practices or standards become acceptable. As the deviant practices are repeated and taught to new nurses, it becomes the social norm for the team. In today’s environment, deviance can arise from a lack of knowledge and close supervision of nursing care.
Nurse leaders must have a fundamental commitment to patient safety and communicate this to staff to counter deviant behavior. In the current environment with so many inexperienced staff, nurse leaders must stay especially vigilant about what is happening in nursing practice. Missed nursing care is widespread, but as a new nurse, I may not understand what can be omitted and what can’t be. My preceptor and charge nurse may not know either.
A nurse educator recently asked me if I thought we would need to teach a nursing 101 course after this pandemic has passed. She raises a good point about how to rebuild best practices moving forward after two years of turmoil on teams. One important strategy is to go back to live skill fairs, perhaps evenly quarterly, as soon as you can to reinforce policies and practices in high-risk/problem-prone areas. These fairs have largely been placed on hold because of social distancing and the strain of staff onboarding. Findings from these skill fairs and deficits in practice discovered can provide a foundation on what to do next and how to more effectively hardwire safety and quality back into our practice. Like the manager in the above situation, we need to be brutally honest about the toll that COVID has had not only on our workforce but also on nursing practice.
© emergingrnleader.com 2022
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