Epistaxis first-aid management: a needs assessment among healthcare providers.

PURPOSE: To perform a needs assessment of epistaxis first-aid measures practiced by family physicians and Emergency Department (ED) staff in London, Ontario, Canada. METHODS: Paper-based multiple-choice questionnaires were distributed to participants. Participant recruitment was conducted in two parts: 1) 28 Emergency Medicine (EM) attending physicians, 21 resident physicians training in the ED, and 26 ED nurses were surveyed while on duty in the ED; 2) 27 family physicians providing walk-in or urgent care and attending a continuing medical education (CME) event were also surveyed. Respondents were asked to identify where to apply compression to the nose and how patients should be positioned during acute epistaxis. RESULTS: Regarding where to apply compression, 19% of family physicians, 43% of EM physicians, 24% of residents, and 8% of ED nurses responded correctly. Regarding positioning, all groups responded similarly with 54-62% responding correctly. Twenty-one percent of emergency physicians, 19% of residents, 11% of family physicians, and 4% of nurses responded correctly to both questions. CONCLUSIONS: Most family physicians, EM attending physicians, ED nurses, and residents could not correctly identify basic first-aid measures for acute epistaxis. This study identifies an area where knowledge is lacking and the potential for improvement in patient management and education.

Multidisciplinary Tracheostomy Quality Improvement in the COVID-19 Pandemic: Building a Global Learning Community.

OBJECTIVES: To report experience with a global multidisciplinary tracheostomy e-learning initiative. METHODS: An international multidisciplinary panel of experts convened to build a virtual learning community for tracheostomy care, comprising a web-based platform, five distance learning (interactive webinar) sessions, and professional discourse over 12 months. Structured pre- and post-webinar surveys were disseminated to global participants including otolaryngologists, intensivists, nurses, allied health professionals, and patients/caregivers. Data were collected on audio-visual fidelity, demographics, and pre- and post-tutorial assessments regarding experience and skill acquisition. Participants reported confidence levels for NICU, pediatric, adult, and family care, as well as technical skills, communication, learning, assessment, and subdomains. RESULTS: Participants from 197 institutions in 22 countries engaged in the virtual education platform, including otolaryngologists, speech pathologists, respiratory therapists, specialist nurses, patients, and caregivers. Significant improvements were reported in communication (P < .0001), clinical assessments (P < .0001), and clinical governance (P < .0001), with positive impact on pediatric decannulation (P = .0008), adult decannulation (P = .04), and quality improvement (P < .0001). Respondents reported enhanced readiness to integrate knowledge into practice. Barriers included time zones, internet bandwidth, and perceived difficulty of direct clinical translation of highly technical skills. Participants rated the implementation highly in terms of length, ability for discussion, satisfaction, applicability to professional practice, and expertise of discussants (median scores: 4, 4, 4, 4 and 5 out of 5). CONCLUSIONS: Virtual learning has dominated the education landscape during COVID-19 pandemic, but few data are available on its effectiveness. This study demonstrated feasibility of virtual learning for disseminating best practices in tracheostomy, engaging a diverse, multidisciplinary audience. Learning of complex technical skills proved a hurdle, however, suggesting need for hands-on experience for technical mastery. While interactive videoconferencing via webinar affords an engaging and scalable strategy for sharing knowledge, further investigation is needed on clinical outcomes to define effective strategies for experiential online learning and virtual in-service simulations.

The Development and Evaluation of Personalized Training in Shared Decision-making Skills for Rheumatologists.

OBJECTIVE: Many factors influence a patient's preference in engaging in shared decision making (SDM). Several training programs have been developed for teaching SDM to physicians, but none of them focused on the patients' preferences. We developed an SDM training program for rheumatologists with a specific focus on patients' preferences and assessed its effects. METHODS: A training program was developed, pilot tested, and given to 30 rheumatologists. Immediately after the training and 10 weeks later, rheumatologists were asked to complete a questionnaire to evaluate the training. Patients were asked before and after the training to complete a questionnaire on patient satisfaction. RESULTS: Ten weeks after the training, 57% of the rheumatologists felt they were capable of estimating the need of patients to engage in SDM, 62% felt their communication skills had improved, and 33% reported they engaged more in SDM. Up to 268 patients were included. Overall, patient satisfaction was high, but there were no statistically significant differences in patient satisfaction before and after the training. CONCLUSION: The training was received well by the participating rheumatologists. Even in a population of rheumatologists that communicates well, 62% reported improvement. The training program increased awareness about the principles of SDM in patients and physicians, and improved physicians' communicative skills, but did not lead to further improvement in patients' satisfaction, which was already high.

Colonoscopy Direct Observation of Procedural Skills Assessment Tool for Evaluating Competency Development During Training.

INTRODUCTION: Formative colonoscopy direct observation of procedural skills (DOPS) assessments were updated in 2016 and incorporated into UK training but lack validity evidence. We aimed to appraise the validity of DOPS assessments, benchmark performance, and evaluate competency development during training in diagnostic colonoscopy. METHODS: This prospective national study identified colonoscopy DOPS submitted over an 18-month period to the UK training e-portfolio. Generalizability analyses were conducted to evaluate internal structure validity and reliability. Benchmarking was performed using receiver operator characteristic analyses. Learning curves for DOPS items and domains were studied, and multivariable analyses were performed to identify predictors of DOPS competency. RESULTS: Across 279 training units, 10,749 DOPS submitted for 1,199 trainees were analyzed. The acceptable reliability threshold (G > 0.70) was achieved with 3 assessors performing 2 DOPS each. DOPS competency rates correlated with the unassisted caecal intubation rate (rho 0.404, P < 0.001). Demonstrating competency in 90% of assessed items provided optimal sensitivity (90.2%) and specificity (87.2%) for benchmarking overall DOPS competence. This threshold was attained in the following order: "preprocedure" (50-99 procedures), "endoscopic nontechnical skills" and "postprocedure" (150-199), "management" (200-249), and "procedure" (250-299) domain. At item level, competency in "proactive problem solving" (rho 0.787) and "loop management" (rho 0.780) correlated strongest with the overall DOPS rating (P < 0.001) and was the last to develop. Lifetime procedure count, DOPS count, trainer specialty, easier case difficulty, and higher cecal intubation rate were significant multivariable predictors of DOPS competence. DISCUSSION: This study establishes milestones for competency acquisition during colonoscopy training and provides novel validity and reliability evidence to support colonoscopy DOPS as a competency assessment tool.

Desarrollo de la competencia de atención comunitaria para residentes de Enfermería Familiar y Comunitaria en una Unidad Docente Multiprofesional provincial. Tres años de experiencia / Community health training for Family and Community Health Nursing residents in a Multiprofessional Teaching Unit. Three years of experience

Objetivo: Conocer el grado el interés de los residentes en áreas formativas transversales de Enfermería Familiar y Comunitaria (EFyC) al inicio de su formación. Valorar el desarrollo de actividades comunitarias en los centros de salud y determinar el grado de satisfacción de los residentes con la formación recibida y actividades realizadas. Método: Se presenta una experiencia sobre metodología docente en salud pública y comunitaria en los residentes de EFyC desde el 2014 hasta el 2017. La formación se dividió en 3módulos formativos de 21h y se completó con 2actividades de campo: un programa de Educación para la Salud (EpS) y un mapeo de activos en la zona básica de salud (ZBS). Se cumplimentó un cuestionario de satisfacción del curso y de las actividades realizadas. Resultado: Durante este período se formaron 27 residentes. El 86,9% consideró la formación en atención comunitaria como muy necesaria. Se realizaron 26 programas de EpS y 17 mapeos de activos de sus ZBS. Con respecto a la satisfacción de la formación, se obtuvo una media global de 4,5 ± 0,1 sobre 5. Conclusiones: Los resultados evidencian un alto grado de interés en atención comunitaria, así como una valoración muy alta sobre las actividades realizadas y la formación recibida. La formación en salud comunitaria durante el período de residencia es un elemento esencial para integrar estas competencias en el rol profesional. Resulta imprescindible la dedicación por parte de las Unidades Docentes en el impulso en esta competencia, capacitando a los residentes en la integración del abordaje biopsicosocial, la orientación comunitaria y el trabajo en equipo en Atención Primaria

Objective: To determine the interest of nursing residents in the training areas of Family and Community Nursing (EFyC) at the beginning of their training, to evaluate community activities in health centres and to determine satisfaction with the training received and activities carried out. Method: We present the experience of training in the public and community health competencies of EFyC Nursing from 2014 to 2017 in a multiprofessional teaching unit. The training was divided into 3 theoretical modules. The training was completed with 2 activities: the design and development of a health education programme and an asset mapping in the basic health area. A questionnaire was completed on satisfaction with the course and the activities carried out. Result: During this period, 27 residents received training. As part of the training process, 26 health education programmes and 17 asset mappings were conducted in accredited health centres. The areas of intervention addressed were: lifestyles, life transitions and health problems. The overall satisfaction with the course was 4.5 ±.1 out of 5. Conclusions: The results show a high degree of interest in this area, as well as high evaluation of the activities carried out and the training received. Training in community health and health education during the period of residence is essential to include these competencies in the professional role. The dedication and involvement of the multiprofessional teaching units is essential in the development of these competences, training the residents through the integration of a biopsychosocial approach, community health and teamwork in primary care

Assessing non-conveyed patients in the ambulance service: a phenomenological interview study with Swedish ambulance clinicians.

OBJECTIVES: To combat overcrowding in emergency departments, ambulance clinicians (ACs) are being encouraged to make on-site assessments regarding patients' need for conveyance to hospital, and this is creating new and challenging demands for ACs. This study aimed to describe ACs' experiences of assessing non-conveyed patients. DESIGN: A phenomenological interview study based on a reflective lifeworld research approach. SETTING: The target area for the study was Stockholm, Sweden, which has a population of approximately 2.3 million inhabitants. In this area, 73 ambulances perform approximately just over 200 000 ambulance assignments annually, and approximately 25 000 patients are non-conveyed each year. INFORMANTS: 11 ACs. METHODS: In-depth open-ended interviews. RESULTS: ACs experience uncertainty regarding the accuracy of their assessments of non-conveyed patients. In particular, they fear conducting erroneous assessments that could harm patients. Avoiding hasty decisions is important for conducting safe patient assessments. Several challenging paradoxes were identified that complicate the non-conveyance situation, namely; responsibility, education and feedback paradoxes. The core of the responsibility paradox is that the increased responsibility associated with non-conveyance assessments is not accompanied with appropriate organisational support. Thus, frustration is experienced. The education paradox involves limited and inadequate non-conveyance education. This, in combination with limited support from non-conveyance guidelines, causes the clinical reality to be perceived as challenging and problematic. Finally, the feedback paradox relates to the obstruction of professional development as a result of an absence of learning possibilities after assessments. Additionally, ACs also described loneliness during non-conveyance situations. CONCLUSIONS: This study suggests that, for ACs, performing non-conveyance assessments means experiencing a paradoxical professional existence. Despite these aggravating paradoxes, however, complex non-conveyance assessments continue to be performed and accompanied with limited organisational support. To create more favourable circumstances and, hopefully, safer assessments, further studies that focus on these paradoxes and non-conveyance are needed.

Does improved postgraduate capacity shift the balance of power for nurse specialists in a low-income country: A mixed methods study.

AIM: To explore nurse specialists' experiences of change and influence on practice two years after graduating with a postgraduate degree. BACKGROUND: In the absence of further study opportunities for nurses in their own country, a master's degree was introduced to train the first group of nurse specialists in Mozambique. DESIGN: Within a hybrid evaluation framework an exploratory, sequential mixed methods design was followed. METHODS: Qualitative data from focus group interviews with nurse specialists (N = 12) led to five thematic data sets from which survey questions were formulated for the sequential quantitative component. FINDINGS: "Change expectations", "Ambiguous practice environments", "Feeling powerless", "Having some influence" and "Workplace support" were emergent themes from interview data. Areas of positive change occurred in research (100%) and the use of evidence (88.9%) and involvement in decision-making (77.8%). For some change did not happen as anticipated-reasons included lack of nurse mentors to support new graduates (55.6%); lesser respect compared with doctors (44.4%) and poor understanding of the value of a master's degree (44.4%). Improvements in service quality and elevating the status of nursing were areas of greatest influence (77.8%). CONCLUSION: Several enabling and limiting factors were identified in the experiences of change and influence on practice of newly qualified nurse specialists. Tacit change with respect to the value of the degree in improving the status of nursing seems not to have affected nurse specialists' own ability and power to influence practice. Improved postgraduate capacity on its own does not empower nurses in their role as specialists. IMPACT: The findings point to a two-tiered strategy to be developed to dismantle barriers to the empowerment and advancement of nurse specialists. The identification of designated nurse mentors is essential to induct and sustain newly graduated nurse specialists. A clear research policy should be developed that supports the conduct of relevant research and the use of evidence in specialist practice.

Experiences of supervision during clinical education among specialised nursing students in Sweden: A cross-sectional study.

BACKGROUND: The importance of the clinical learning environment in nurse education has gained increasing attention over the last decades. However, there is a lack of research on the learning environment, its significance and meaning in specialist nurse education. OBJECTIVE: The objectives of the study were to investigate specialised nursing students' experiences of supervision during clinical practice and to compare students who were satisfied with the supervision with those who were dissatisfied with respect to a) organisation of supervision and number of preceptors, as well as time allocated by preceptors for b) supervision, c) reflection, d) discussion of intended learning outcomes, and e) assessments of students' performance by preceptors. DESIGN: This study used a cross-sectional design. SAMPLE AND SETTINGS: A convenience sample of specialised nursing students was derived from five Swedish universities in the years 2016 and 2017. METHODS: Data were collected using a questionnaire. Statistical analyses and a qualitative conventional content analysis were performed. RESULTS: While almost all specialised nursing students reported that there had been time for discussion on their performance assessment, almost half of the students reported not getting time for supervision, or time for reflections and discussions on intended learning outcomes with the preceptor. Students reporting having time allocated for supervision by preceptors were found to be more satisfied with supervision. It was described as important that the preceptor(s) acknowledged the students previous work experiences. Even though being a registered nurse, reflections and feedback were described as valuable for the students learning. Several preceptors were described as positive allowing a broader picture and different views regarding working as a specialist nurse. CONCLUSIONS: This study indicates that supervision, in terms of discussions and reflections, of specialised nursing students is significant for learning experiences and satisfaction during clinical placement.

Skills for generalist and specialist nurses working in the prevention and control of infections in Brazil. / Competências para enfermeiros generalistas e especialistas atuarem na prevenção e controle de infecções no Brasil.

OBJECTIVE: to define the competencies for the prevention and control of healthcare-related infections that should be developed by the generalist nurse and the specialist nurse in infection control in Brazil. METHOD: the Delphi technique, developed in four rounds, was used. Thirty-one nurses and eight physicians participated in the study, with expertise in infection prevention and control. Data were collected using open-ended questionnaires, whose answers were treated using the content analysis technique. Structured instruments were used to evaluate the importance of each competency using a Likert scale. Data were analyzed and presented in a descriptive way, use of median and coefficient of variation. RESULTS: the competences were organized in 4 core, 14 generic and 17 specific, with name and description of each competency. CONCLUSION: the definition of competencies for the prevention and control of healthcare-related infections is the first step to begin the rethinking of the teaching and learning process in the initial training of nurses. The data found in the present study may help to restructure education and support permanent education programs in health.

Core Competencies Required for Gastroenterology Nursing Specialists in China.

Healthcare professionals responsible for patients with gastrointestinal diseases need a particular level of nursing knowledge and abilities to ensure excellent care. This study aims to propose a set of core competencies for the gastroenterology nursing specialists (GNS) in China. This research integrates quantitative and qualitative research methods. Literature review, semistructured interview, and the Delphi approach were used to develop the core competency items of GNS in China. SPSS 16.0 was used to analyze the data. Finally, 28 of 30 experts participated in the study resulting in a consensual list containing 7 domains (clinical nursing practice, communication and collaboration, education and counseling, critical thinking, leadership, ethical and legal practice, and professional development), 23 aspects, and 66 competencies required for GNS. The authority coefficient (Cr) of the consensus was 0.77, and the Kendall (W) value of each level of competencies all scored above 0.5. Results of the study can serve as a foundation of work performance evaluation for GNS as well as promote nurses' professional development.

Teaching nurses to teach: A qualitative study of nurses' perceptions of the impact of education and skills training to prepare them to teach end-of-life care.

AIMS AND OBJECTIVES: To explore nurses' perceptions of the impact of a programme designed to train them to teach end-of-life care. BACKGROUND: Central to national and international policies are the need for generalist healthcare staff to have education in end-of-life care. Much end-of-life care education is provided by specialist nurses who often have no specific education development to prepare them to teach. To address this gap, an Education Development Programme (EDP) was developed and delivered to specialist nurses. We report on the evaluation of the programme. DESIGN: A qualitative programme evaluation methodology was adopted. METHODS: Data were collected through focus groups, at three hospice education centres in North West England, with a total of 20 participants. Nurses who had completed the EDP were purposively sampled. Data were digitally audio-recorded and subjected to thematic analysis to organise, reduce and refine the data. Ethical approval was obtained. COREQ guidelines have been adhered to in the reporting of this study. RESULTS: Two main themes were identified; learning to teach and building skills to change teaching practice. Participants felt more confident and better prepared to teach. CONCLUSIONS: It cannot be assumed that specialist staff, with teaching in their role, have the skills to facilitate learning. This programme offers a potential method of improving facilitation skills for nurses who have an education element to their role. RELEVANCE TO CLINICAL PRACTICE: Quality end-of-life care is only possible with a skilled workforce, confident and able to apply the principles of compassionate end-of-life care to everyday practice. Appropriately trained, specialist staff are better able to teach others how to deliver good quality end-of-life care. Specialist staff with teaching responsibilities should be provided with, or engage in, continuous professional development to develop their skills and improve their efficacy when teaching.

Benefits of the epilepsy specialist nurses (ESN) role, standardized practices and education around the world.

Epilepsy, often considered as a stigmatizing disease, affects 65 million people worldwide and is frequently associated with comorbidities that increase both direct and indirect costs. The degree of impact on quality of life and the cost of care differs depending on the social and health care organizations in place, political, medico-economic and/or socio-cultural contexts. Across the globe, healthcare is provided by nurses in primary care, urgent or emergency care, and within specialized domains of practice. In Epilepsy the global care could be enhanced by developing standardized nursing education in close collaboration with other caregivers. The impact of epilepsy nursing care has been documented in some developed countries, but the diversity of nursing practices and professional education of nurses raise difficulties in generalizing these findings. Specialized education in epilepsy will improve access, treatment and ultimately the quality of life of patients.

Assessment of COPD-Related Knowledge Among Internal Medicine Nurses: A Cross-Sectional Study.

Background: Since most internal medicine nurses work with chronic obstructive pulmonary disease (COPD) patients daily, their ability to meet the needs of COPD patients is an important issue. Our study aimed to assess COPD-related knowledge in internal medicine nurses. Methods: A descriptive cross-sectional study including 175 participants was conducted to investigate COPD-related knowledge levels among internal medicine nurses in a large top-ranked tertiary hospital in China. The Bristol COPD Knowledge Questionnaire (BCKQ) was used to test COPD-related knowledge levels in the participants. Results: Overall BCKQ score for all nurses in this study was 35.76 ± 5.49. In comparison with non-respiratory nurses, the overall score among respiratory nurses was significantly higher (39.01 ± 3.95 vs 33.32 ± 5.23, p < 0.001). The mean scores for four topics (epidemiology, breathlessness, oral steroids, and inhaled steroids) were less than 3 among both respiratory and non-respiratory nurses. Subgroup analysis of specialist respiratory wards showed that nurses in the chronic airway disease ward had the highest overall knowledge score (40.47 ± 4.03). Linear regression analysis demonstrated that the overall BCKQ score was significantly related to the population of nurses (ß coefficient = 3.016, 95% confidence interval [CI]: 0.953-5.079, p < 0.01), education (ß coefficient = 4.710, 95% CI: 1.979-7.440, p < 0.01) and previous rotation in respiratory wards (ß coefficient = 3.871, 95% CI: 1.776-5.967, p < 0.001). Conclusion: Internal medicine nurses at this tertiary hospital showed deficits in COPD-related knowledge. Appropriate and systematic education about COPD knowledge and strengthening rotation among different wards are necessary for improving COPD-related knowledge levels among internal medicine nurses.

Trends in the primary health care nursing workforce providing diabetes care in Auckland, New Zealand: A cross-sectional survey.

AIMS: To describe trends from 2006-8 to 2016 in demographic, education and work settings of the primary health care nursing workforce who provide diabetes care in the Auckland region. METHODS: A total of 1416 practice, Accident and Medical, district and diabetes specialist nurses were identified who provide community-based care. Of those, 459 were randomly selected and 336 were interviewed in 2016, and were compared with 287 nurses interviewed in 2006-8. RESULTS: A 73% response rate was attained in 2016. Compared with nurses in 2006-8, primary health care nurses in 2016 were younger, less experienced, more likely to be Asian, undertook more post-graduate education, worked more in Accident and Medical Clinics and worked in larger practices with ≥4 doctors. However, less worked with a dietitian or received visits from specialist nurses compared with nurses in 2006-8. Significantly more nurses in 2016 had their own room for administrative work and the ability to email patients suggesting greater autonomy. CONCLUSIONS: Major demographic, educational and workplace changes have occurred in the Auckland primary health care nursing workforce from 2006-8 to 2016. A significant increase in practice nurses and a large decrease in the number of diabetes specialist nurses were evident, in the Auckland region.

Advanced practice nursing: Nutrition Nurse Specialist role and function.

BACKGROUND: Different disciplines should be represented in Nutritional Support Teams, e.g. a physician, dietician, pharmacist and a nurse. The latter one can function as an Advanced Practice Nurse, which implicates that he or she must have sufficiently thorough knowledge, attitudes and competences to fulfill the profile of a nutritional expert in the field of clinical nutrition. METHODS: Description of the scope of practice, education and added value related to a Nutrition Support Nurse, based on detailed published competency profiles. RESULTS: The described competencies reflect the advanced role and clinical expertise of a Nutrition Support Nurse. She can make a significant contribution to the overall quality of nutritional care, uncover the multidimensional aspects of nutrition, monitor effectiveness/ appropriateness of nutrition therapy and improve clinical outcomes. CONCLUSIONS: A Nutrition Support Nurse can incorporate nutrition nursing in the overall nutrition support, acting as an important player for users, carers and the healthcare organization in general.

Physical Health Care for People with Severe Mental Illness: the Attitudes, Practices, and Training Needs of Nurses in Three Asian Countries.

People with severe mental illness (SMI) have considerable unmet physical health needs and an increased risk of early mortality. This cross-sectional survey utilized the Physical Health Attitude Scale (PHASe) to examine the attitudes, practices, and training needs of nurses towards physical health care of people with SMI in three Asian countries (Hong Kong, Japan, Qatar). Cross-country differences were explored and linear regression was used to investigate if nurses' attitudes and confidence were associated with their level of involvement in physical health care. A total of 481 questionnaires were returned. Hong Kong nurses were less involved in physical health care than those from Japan and Qatar. Nurses' attitudes and confidence were significant predictors of their participation in managing physical health. Compared with western countries, more nurses in this study felt that mental illness was a barrier to improving physical health. Three-quarters reported that they needed additional training in promoting cardiometabolic health. The perceived need for additional training in physical health care was held by Mental Health Nurses (MHN) irrespective of their type of nursing registration and nationality. Nurse educators and service providers should reconsider the physical health care training requirements of nurses working in mental health settings in order to improve the physical health of people with SMI.

Abilities and barriers to practicing evidence-based nursing for burn specialist nurses.

OBJECTIVE: To explore the abilities and barriers of practicing evidence-based nursing (EBN) for burn specialist nurses so as to provide rationales for its clinical training and practice. METHODS: From January 2016 to March 2016, a cross-sectional survey was conducted with a self-designed questionnaire among burn specialist nurses in Hunan Province. Data analysis was performed with SPSS software (version 20). RESULTS: Burn specialist nurses in Hunan Province had diminished EBN abilities. The three procedures of EBN with the lowest score were "summarizing evidence through systematic reviews", "rigorous evaluations of evidence" and "systematic literature searches". And the three procedures of "clarifying problems", "disseminating evidence" and "introducing evidence" scored the highest. The systematic literature retrieval ability of nurses at class III general hospitals was higher than that of class II counterparts (P=0.001). Thus EBN ability was positively correlated with barriers to practicing EBN, English proficiency, research experiences and educator status. CONCLUSION: Burn specialist nurses at classes III & II general hospitals in Hunan Province had poor EBN abilities. Influencing factors of EBN ability included barriers to practicing EBN, English proficiency, research experiences and educator status. Therefore it is imperative to implement targeted trainings and integrated managements for improved ability of practicing EBN.

Finding the jewels in adversity: reflections on a secondment.

Laura Lennard, on secondment as Children's Diabetes Nurse, Hemel Hempstead Hospital, West Hertfordshire Hospitals NHS Trust, shares what she has learned from the sometimes painful experience of stepping out of her comfort zone and learning the ropes in a new role.