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The ABCDEs of nursing: Essentials for new nurses to know

Dabkowski, Melissa Ann MSN, RN

doi: 10.1097/01.NURSE.0000476232.80384.1a
Feature: NEW HORIZONS
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New nurses need support and guidance to ease their transition into practice. By understanding and implementing these core components—advocating, breathing, communicating, documenting, and educating—they improve patient care and increase their confidence and satisfaction as nurses.

Melissa Ann Dabkowski is a registered nurse at Middlesex Hospital in Middletown, Conn.

The author has disclosed that she has no financial relationships related to this article.

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CONGRATULATIONS on making it through nursing school and passing the National Council Licensure Examination. Welcome to the profession! This may be difficult to hear, but a lot of research suggests that as a new nurse, you may be subject to role performance stress, moral distress, discouragement, and disillusionment when you're first introduced into professional nursing practice.1 In the United States, 26% of new nurses leave their first nursing job and 2% leave the profession altogether during the first 2 years of nursing.2 That being said, the nursing profession needs you: New nurses are essential to healthcare because the supply and demand of nurses will continue to vary depending upon population growth, the aging of the nursing workforce, and changes in healthcare reimbursement.3

As a new nurse, you'll need support and guidance to ease your transition into the profession. This article outlines the ABCDEs of nursing: advocating, breathing, communication, documentation, and education. These are core components of nursing and understanding them will benefit your patients as well as increase your confidence and satisfaction as a nurse.

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Advocate.

As nurses, we spend a lot of time with the patient. For this reason, we're one of the patient's best advocates. This essential nursing role is described in the American Nurses' Association Code of Ethics.4 Advocacy encompasses acting in the patient's best interest, supporting patient rights, and protecting and comforting patients who can't communicate.5

It's important to empower your patients and their families so they can make informed healthcare decisions. Encourage patients to ask questions. You aren't expected to know all the answers, so draw on available resources, such as other members of the interdisciplinary health team. For example, if the patient has financial concerns, contact the social worker.

Mistakes happen; we're only human. As an advocate, you must promote a safe environment by owning up to mistakes and correcting them. As a new nurse, I once forgot to cut a patient's BP medication in half. I realized my mistake after the patient had received the wrong dose. I went to my manager and told her what had happened; she guided me through notifying the healthcare provider (HCP) and patient. It was scary to admit the error, but doing so was essential to provide safe patient care. The HCP checked in with me throughout the day to monitor the patient's vital signs. I also reported the error through my institution's online reporting system so it could be reviewed and help improve the overall medication administration process. Fortunately, my patient experienced no adverse reactions from the medication error.

Any time something happens that can affect patient safety, report it. Besides being the right thing to do, it will lead to a better outcome for your patient and may help your facility improve processes and prevent similar errors in the future.

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Breathe.

Not just in the “airway, breathing, circulation” sense. You should breathe. Nursing can be very stressful. Some days you'll go home from work and feel physically, mentally, and emotionally exhausted. One of the easiest ways to relieve stress at work is to take some breaks along with some good, deep breaths. When you're stressed, taking some deep cleansing breaths can lower your heart rate and BP.6

During your shift, don't skip scheduled breaks. After work, give yourself time to unwind and release thoughts about work so you don't hold on to that stress at home. Take care of yourself the way nurses teach patients to: through adequate sleep, a healthy diet, and regular physical exercise. Taking care of your stress, with something as easy as breathing will help you combat the unwanted “b,” burnout!

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Communicate.

The Joint Commission reports that about 80% of serious medical errors involve miscommunication between caregivers.7 As nurses, we need to practice effective communication with all members of the interdisciplinary team. This involves collaborating with everyone involved in your patient's care. The more you do this, the more you encourage open communication among team members and demonstrate mutual respect.8 It also ensures that all team members know and follow the patient's care plan.

Communicating effectively during handoff report is especially important for patient safety. A good handoff report will take some time. Ask a manager or mentor to review your reports so that he or she can give you feedback. Over time, your skills will grow as you learn about the most pertinent information to provide.

Communicating issues to HCPs is important, but can be intimidating when you begin nursing. If this communication is done over the phone, take a minute to do a practice run with a more experienced colleague to increase confidence.

When communicating with a patient, always be respectful and therapeutic. Communication isn't just about the words you use, but also your manner of speaking, body language, and listening skills.9 To actively listen, show interest and give your patient your full attention. Besides helping to foster patient respect and trust, it lets you pick up cues from the patient about their anxieties or gaps in knowledge about care. Paraphrase and repeat what the patient says to improve the quality of communication.9 Your ability to communicate with patients can make a big difference in their perception of their care.

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Document.

A patient's medical record is a legal document, so it's important to be thorough and accurate with your charting. Remember, if a legal issue crops up with one of your patients, you likely won't know until years later. At that point, you're unlikely to remember much about that patient, so you'll need to rely on your documentation for a clear delineation of the events as they occurred. Your documentation should be factual, accurate, and timely. It shouldn't include your assumptions or interpretation of events. If you enter a room and find your patient on the floor, for example, don't document “the patient fell on the floor.” That would involve making an assumption. Instead, document the facts: “The patient was found sitting on the floor in front of her chair.”

One recommendation for improving documentation is to do focus charting using the Data-Action-Response (DAR) method. In this format, D = Data (both subjective and objective); A = Action or nursing intervention; and R = Response of the patient (evaluation of the effectiveness of the intervention).10 For example, D: The patient's blood glucose level is 58 mg/dL and he's diaphoretic. A: Glucose tablets administered as prescribed; HCP notified. R: Patient's blood glucose level after 15 minutes is 83 mg/dL. Patient's skin is warm and dry.

Additionally, nursing documentation can affect reimbursement from Medicare or private insurance companies. Maintaining documentation as accurately and thoroughly as possible will keep you in compliance with standards of care. Become educated about quality indicators and core measures relevant to your practice area so you don't miss important areas of documentation. When in doubt, ask your manager or an experienced colleague to review your documentation.

Last, look at your documentation as a story.10 Think back to communication. The documentation of your assessment findings, in addition to your patient handoff report, tells the next nurse about any changes in the patient's clinical status that must be monitored or investigated.

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Educate.

Nurses are educators. We have to use every opportunity to educate our patients about their healthcare and treatment plan. In many healthcare settings time is limited, but don't fail to assess and address any barriers to learning. Use professional medical interpretive services to overcome language barriers. Assess the patient's preferred learning styles so you can teach in a manner that's best for the patient. Assess family members who are closely involved in the patient's care and, with the patient's permission, include them in patient education.

Research has shown that patients remember and understand less than half of what clinicians explain to them.11 Using the teach-back method is one way to accurately assess if a patient has understood your teaching. This involves asking patients to repeat in their own words what they need to know.11 A simple “yes” isn't enough to confirm a patient's understanding; instead, ask the patient to repeat or explain discharge instructions. A response such as, “I'll call my doctor if I gain 2 pounds overnight or 5 pounds total in a week,” is a more accurate indication that the patient understands and will follow recommended guidelines when home.

Educate yourself too! Nursing involves lifelong learning because healthcare is always changing. Advancing your degree is one way to increase your knowledge, and research suggests that nurses with a baccalaureate or higher degree are better prepared for greater professional responsibility and more complex practice.12 Patients also benefit from nursing education; studies show an association between BSN staffing and positive patient outcomes.12

Other ways to advance your education include continuing-education courses. These are often required for your nursing license and by your employer. Attending conferences is a great pathway to continuing education. Other pathways to ongoing education include subscribing to a nursing journal and obtaining certification in your specialty practice area.

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Using the ABCDEs to succeed

Focusing on the ABCDEs will help you grow as a nurse and gain confidence in your skills as you transition into the profession. Never be afraid to ask for support from your colleagues, and remember that you do make a difference to your patients.

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REFERENCES

1. Duchscher JE. Transition shock: the initial stage of role adaptation for newly graduated registered nurses. J Adv Nurs. 2009;65(5):1103–1113.
2. Flinkman M, Isopahkala-Bouret U, Salanterä S. Young registered nurses' intention to leave the profession and professional turnover in early career: a qualitative case study. ISRN Nurs. 2013;2013:916061.
3. U.S. Department of Health and Human Services. The future of the nursing workforce: national- and state-level projections, 2012-2025. 2014. http://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/workforceprojections/nursingprojections.pdf.
4. American Nurses Association. Code of ethics for nurses. 2015. www.nursingworld.org/codeofethics.
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6. Breath control helps quell errant stress response. Harv Womens Health Watch. 2006;13(12):6–7.
7. The Joint Commission. Joint Commission center for transforming healthcare releases targeted solutions tool for hand-off communications. Jt Comm Perspect. 2012;32(8):1, 3.
8. Boykins AD. Core communication competencies in patient-centered care. ABNF J. 2014;25(2):40–45.
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12. Fauteux N. The case for academic progression. In: Ladden MD, Hassmiller SB, eds. Charting Nursing's Future. Princeton, NJ: Robert Wood Johnson Foundation; 2013:1–8.
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