A brief Introduction to Oncology: Part I

Since graduating in September last year I’ve been working in Oncology, it’s been a steep learning curve and there’s still so much more to learn but I thought I’d share a few bits and pieces that might be useful background reading for anyone with an oncology placement coming up! Skip to the bottom of the page for a list of useful resources and a glossary of oncology terms.


Cell Biology Basics

Cancer can be defined as malignant uncontrolled growth from abnormal cell division. Before any new placement I found it useful to recap the relevant anatomy and physiology beforehand, therefore I thought it might be useful to include a mini recap of the basics of the cell cycle. If your oncology placement has a particular sub-speciality, for example haematology or gynaecology, you may also find it useful to revise the relevant body system.

cell cycle

Mitosis can be subdivided into 4 stages, prophase, metaphase, anaphase and telophase. G1 is when cellular contents (excluding chromosomes) are duplicated, S phase is where DNA is synthesised and duplicated and the G2 phase is when checking for errors in chromosome repair occurs, then the cells divide to produce two daughter cells. From G1, some cells may enter G0, a resting phase when cell division ceases.

Different cytotoxic drugs act on different parts of the cell cycle. As such you may find that different types of chemotherapy are given in combination to have a synergistic effect.

hallmarkswheel

The Hallmarks of Cancer, as described by Hanahan and Weinberg, illustrates the different types of mutations within carcinogenesis that enable survival and uncontrolled growth of cancer cells in tumours. Researchers can use these hallmarks as a focus for mechanisms of cytotoxic drugs. For example; Bevacizumab (Avastin), prevents angiogenesis so it slows the growth of new blood vessels, preventing the growth of this new vasculature supplying the tumour.

Cancer Staging

TNM staging is the most widely used clinical staging tool for solid tumours (does not apply to CNS tumours or haematological malignancies). It categorises the stage of the cancer with three simple alphanumeric codes corresponding to the categories of the primary tumour, involvement of lymph nodes and whether the cancer has metastasised. Prefixes and codes for additional modifiers can be added to give additional clinical information including details such as resection margins or specific histology of samples.

TNM staging

A number of disease group specific staging classifications are also used, a few you may come across are: Dukes (colorectal), Clarke & Breslow (melanoma), Lugano classification (lymphoma), Gleason score (prostate), and Robson staging system (renal cell carcinoma).

Communication

As with any placement area, communication is key! The following tools may be useful to recap  before starting your next placement.

SBAR

For acute situations the SBAR handover tool is great to clearly handover key clinical information. It provides structure to help you provide clear and concise information.

When exploring broader concerns with patients and relatives the Sage & Thyme communication tool can be really useful to help gather information and respond with empathy. Developed at UHSM in 2006 it can provide structure to responses in emotive situations, actively listening with the patient guiding the solution. (I’d also strongly recommend going on this course if you ever get the opportunity to go while on placement or in your future career.)

If you’re dealing with patients or relatives who wish to make a complaint the LASTED mnemonic can be useful to help structure a response but in your role as a student it’s best to escalate the situation to a member of staff; Listen, Acknowledge, Solve, Thank, Explain, Document.

IMG_5761

Source: Learning aid from Critical Care Department at Manchester Royal Infirmary

Body language, although non-verbal is an important communication tool. SOLER, SURETY and other similar models help illustrate the key components in effective non-verbal communication.

Last but not least, always remember to introduce yourself to patients and ask their permission before performing or observing any procedure! #hellomynameishello-my-name-is-logo-web

Palliative Care

From the latin Palliare, meaning ‘to cloak’, palliative care is essentially the relief of pain and associated symptoms without treating the underlying cause of the condition. You may come across this as ‘Best Supportive Care’ in a move away from negative connotations of palliative care in the media.

Dame Cecily Saunders was the founder of the hospice movement and a pioneer in palliative medicine. As increasing numbers of people began to die in a hospital environment rather than at home, she recognised the inadequacy of care and the fears of patients. Particularly regarding a terminal cancer diagnosis, where pain relief was insufficient due to the prevailing medical beliefs surrounding opiates. She led an evidence based medical and social change to provide holistic care encompassing physical, spiritual and psychological well-being in the last days of life.

Within palliative care you’ll gain exposure to pain management, controlling nausea and secretions, as well as learning how to manage other issues such as, constipation, terminal restlessness and spiritual distress. This will be in cases where a patient’s primary cancer has spread to other organs and is no longer considered curable, some patients may have a longer prognosis and better quality of life and others will have a much more limiting diagnosis so there can be a wide spectrum within palliative care, therefore care should accordingly be holistic and individual. It’s also imperative to discuss a patient’s preferred place of care and preferred place of death as part of the holistic assessment and Advance Care Planning, you may find the 5 Stages of Grief (Denial, Anger, Bargaining, Depression and Acceptance) by Elisabeth Kubler-Ross a useful resource as a framework to understand the grieving process.

Despite a life limiting metastatic cancer diagnosis there can still be treatment options sometimes this will include palliative intervention such as chemotherapy, radiotherapy and also surgeries. Sometimes hormone therapies or receptor specific SACT (for example, Trastuzumab (Herceptin) in HER2 positive breast cancer). In these cases the aim will be to prolong life and improve remaining quality of life. In these cases it’s important for the medical team proposing the treatment to have sensitive but frank discussions with the patient to ensure there are no misconceptions around the purpose of any proposed treatments.

On that note, remember that oncology isn’t all doom and gloom!! You may find that some people may comment that they think it must be a depressing job but it can be a really rewarding  and holistic environment. Cancer is a very emotive topic and most people will have a friend or family member who has been affected by cancer.

Although the prevalence of cancer may have increased in recent years, the overall incidence of cancer has remained fairly stable . This is due to an increase in overall life expectancy leading to an older demographic of patients with cancer who, some decades ago would likely have died of other comorbidities. Recent developments in anti-cancer therapies has led to an increase in patients living with cancer, including conditions which would have historically been untreatable.

However, as with any areas of nursing there you will experience end of life care and care of the deceased person. It’s important to remember that most people have had very limited experience with death and it can sometimes be hard to process difficult situations that your peers can’t relate to.

Remember if you’re struggling or feeling upset it’s absolutely okay to take yourself off to a quiet corner to collect yourself if you need to, you are supernumerary! Don’t underestimate the benefits of a debrief with your preceptor and remember that your AA and the PEF are always available. If you want to talk to somebody out of office hours the Greater Manchester Nightline listening and information service is open from 8pm-8am during term time.

ECOG Performance Score

This grading tool is commonly used in all areas of oncology to assess disease progression and how this impact’s on a patient’s activities of daily living. Created by the Eastern Cooperative Oncology Group, this 0-5 scale is something you will come across on any oncology placements, familiarising yourself with the descriptions of these categories will help you understand the impact of performance status on patient’s day to day experiences.

Grade 0 : Fully active, able to carry on all pre-disease performance without restriction
Grade 1 : Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
Grade 2 : Ambulatory and capable of all self care but unable to carry out any work activities, up and about more than 50% of waking hours
Grade 3 : Capable of only limited self care, confined to bed or chair more than 50% of waking hours
Grade 4 : Completely disabled, cannot carry on any self care, totally confined to bed or chair
Grade 5 : Dead

Specific side effects are graded primarily using the CTCAE (Common Terminology Criteria for Adverse Events) database. You can view this online here.

Neutropenic Sepsis

Neutropaenia is defined as having a Neutrophil count of less than 1. Chemotherapy can cause a drop in Neutrophil count, some patients on cytotoxic treatment will often be given a Granulocyte Stimulating Factor (GCSF) prophylactically to prevent neutropaenia.

Sepsis

The nadir (lowest point) of a patient’s white cell count usually occurs 7-10 days after chemotherapy. It’s important to consider this if you suspect sepsis.

Sepsis is a life threatening immune response to infection. Make sure that you escalate your concerns quickly to your mentor or another nurse if you think a patient may have sepsis, then they can begin treatment within the hour to improve outcomes. You can find out more information about the Sepsis Six campaign here: www.sepsistrust.org 

Metastatic Spinal Cord Compression

MSCC is an oncological emergency, it occurs when the pressure from a tumour site begins to compress the spinal cord and pain and neurological symptoms occur. This can happen from either a tumour within the CNS system growing within the spinal cord itself, from a tumour pressing on the vertebrae or from vertebrae collapsing and pressing upon the cord as they are weakened by metastases within the bone (bony metastases are more common in progressive Prostate, Lung and Breast cancers).

A ‘red flags’ early warning system has been developed to help quickly identify symptoms that can indicate cord compression. If you suspect a patient may have MSCC it’s important to act quickly and escalate this. The longer the symptoms occur the worse the prognosis can become for the patient and paralysis can become permanent.

MSCC

Its also important to consider these red flags in other clinical settings, such as A&E because ~25% of patients who present with MSCC do not have a diagnosed primary cancer. MSCC is a palliative condition as the cancer has already spread and mestastasized to other sites but it’s still really important to diagnose and treat to prevent paralysis. Even if patients aren’t having active treatment and are being managed with best supportive care, communication is really important as early treatment can mean improved quality of life, but patients may be reluctant to have a hospital admission if their preferred place of care at the end of life is at home.

Chemotherapy Induced Nausea & Vomiting

CINV is one of the main worries of patients undergoing chemotherapy. Since the first chemotherapy treatments were used in the 1940s, antiemetics have come along a long way. Although some drugs, such as Cisplatin, are still highly emetogenic, CINV is able to be better managed through use of anti-sickness medications since it was first licensed for use in 1979. However, due to the portrayal of chemotherapy in films and television, CINV is often a source of great worry for patients. Therefore it’s important to communicate well with your patients to provide information and reassurance and assess the effectiveness of their anti-emetics.

The main causes of CINV are sensitivity of the GI mucosal lining, stimulation of the 5HT3 receptors and direct stimulation of the chemoreceptor trigger zone, although some pathways are unknown. Some common categories of antiemetics are listed below: Most can be given by a variety of routes of administration, you can check these in the BNF, on Medusa (an online injectable medicines guide) or the electronic medicines compendium. 💉💊

Antihistamines- Cyclizine: H1 receptor antagonist. Main side effect: drowsiness but also has anti-muscarinic properties causing xerostomia (dry mouth), blurred vision and urinary retention. Most commonly used for drug induced N&V but also useful in pregnancy as cyclizine is non teratogenic. Hepatic metabolism, half life approximately 20 hours. Note that cyclizine and metoclopramide can’t be given together.

Antimuscarinic- Hyoscine: main mechanism of action is competitive inhibition at M1 receptor. Classic side effects of antimuscarinic drugs may be present- dry mouth, blurred vision and urinary retention.

Dopamine receptor antagonists- Domperidone:  A pure dopamine receptor antagonist, domperidone is often used for drug induced N&V and postoperatively. Metoclopramide: At higher doses metoclopramide also acts as a 5-HT receptor antagonist, this dual action makes it especially effective in CINV. It also has prokinetic effects- this means the rate of gastric emptying is increased alongside an increase in muscle tone of the gastroesophageal sphincter. They are both metabolised in the liver and have significant first pass metabolism.

5-HT receptor antagonsists- Ondansetron, Palonosetron, Granisetron: These drugs all act on 5HT3 receptors within the gut but also in the chemoreceptor trigger zone within the brain. Ondansetron is very commonly given with emetogenic chemotherapies, it’s important to note that for patients  over 65 years old, it should be administered in a bag infused over 15 mins to reduce risk of long Q-T syndrome but if given as a bolus should be given slowly to avoid vein irritation- “Zofran Flare”. Constipation is a common side effect. Palonosetron has similar properties but is longer lasting.

Neurokinin receptor antagonists- Aprepitant: Also known as Emend, it acts in the CNS on NK1 receptors. Aprepitant also has a secondary effect of increasing the effects of 5-HT receptor antagonists and corticosteroids. It is absorbed in the GI tract and metabolised by the liver. Aprepitant can interact with Warfarin, decreasing its effect.

Corticosteroids- Dexamethasone is an example of a corticosteroid given for CINV, in itself it only has weak antiemetic effects but has an additive effect when given with 5-HT receptor antagonists.

Other antiemetic compounds- There have also been recent studies into the use of herbal compounds such as ginger which was previously used in traditional Chinese medicine and mint to investigate their antiemetic properties.

You can browse other side effects from chemotherapy on the Common Terminology Criteria for Adverse Events (CTCAE) database.

 

Alternative Therapies

As with all nursing specialities, it’s important to ensure that we provide evidence based practice. Some patients may have queries about alternative therapies they have heard about. This can include things like dietary advice such as eating peach stone extract and can be quite dangerous (http://scienceblog.cancerresearchuk.org/2017/11/01/alternative-cancer-therapies-the-potential-impact-on-survival/). Even some over the counter remedies from health food shops, such as St. John’s wort, can have adverse interactions with medication so it’s always best for patient’s to consult their medical team before taking any additional supplements. Patients may also decline treatment in favour of unregulated and unproven therapies if they are worried about side effects, which reiterates the importance of effective and empathetic communication to address patients concerns and allow them to make informed decisions about their care.

The benefits of complementary therapy alongside conventional treatment should not be understated. Relaxation techniques can be beneficial for needlephobic patients during cannulation or for claustrophobic patients requiring scans or radiotherapy using molded masks. Research has also been done into acupuncture to help prevent peripheral neuropathy.


More topics to follow in An Introduction to Oncology: Part II, including an overview of Central Venous access devices, Scalp cooling, Immunotherapy treatments, Radiotherapy and other palliative care emergencies such as hypercalcaemia and arterial bleeds, watch this space! If there’s any other topics you’d like to be included or to give feedback, please use the form below!

Many thanks to my fantastic preceptor Laura for all your advice and support in helping me survive my first year being qualified and also for proofreading this article!


Useful Resources:

I’d also really recommend The Emperor of all Maladies: A biography of Cancer, by Siddhartha Mukherjee if you’re interested in oncology and a bookworm like me!

Glossary:

Adjuvant Therapy- Treatment (usually hormone therapy, chemotherapy or radiotherapy) given after surgery to ‘mop-up’ any remaining cancerous cells.

Brachytherapy- Radioactive seeds planted within a patients tumour, often used in prostate, cervical and endometrial cancers.

Cancer of Unknown Primary- See also Malignancy of Undefined Origin. True CUP is a very small percentage of MUO patients and has implications for treatment options if the primary cell line is unknown. Provisional CUP is the terminology used until a primary diagnosis has been made or confirmed as a true CUP.

Carcinogen- Substances known to cause cancer.

Carcinoma- Cancers which originate from tissues that line internal organs or the skin.

Clinical Oncology- Medical specialty focussing on the treatment of cancer with radiotherapy.

Concurrent- Different modalities of treatment given at the same time, for example chemotherapy alongside radiotherapy.

Cytotoxic- A substance toxic to living cells.

Emetogenic- A substance with the capacity to introduce vomiting (emesis) and nausea.

Dysplasia- The presence of an abnormal cell type, whose growth may be a precursor to cancerous tissue.

In Situ- A Carcinoma In Situ means the tumour has not spread from its original location.

Local Therapy- Treatment specific to the affected area such as surgery or radiotherapy.

Malignancy of Undefined Origin- The term used until a CUP is diagnosed or a primary site is discovered either through scans or histology from biopsies.

Medical Oncology- Medical specialty focussing on the treatment of cancer with drugs.

Metastasis- The spread of cancer from a primary site to other organs of the body either via the bloodstream or lymphatic system or through direct infiltration of adjacent organs by the tumour.

Neo-Adjuvant- Anti-Cancer therapies given to shrink the tumour initially before second stage treatment, usually surgery so the tumour is easier to resect.

SACT- Systemic Anti Cancer Therapy. This encompasses both chemotherapy and immunotherapy.

Advertisements

Finding your feet in third year: a lesson from A&E

*Disclaimer: this post includes description of a traumatic situation which some may find distressing* 

When I started 3rd year, I was excited! I had a fantastic end to second year, and I truly felt ready to enter my final year of my degree. But with that excitement came the endless worrying about jobs, dissertation, and work for other modules. When placement began, I realised I felt like a complete novice again! Despite only having two months off over summer, I felt like I couldn’t remember how to do anything on placement (clinically speaking). I was even putting on blood pressure cuffs the wrong way. Everyone asked me what year I was in, and saying “I’m in third year, but I don’t know what I’m doing” every time was ruining my confidence.

It wasn’t until my 5th shift when I finally started to feel less on edge. I was working in resus (for the most critically ill patients in a&e), and we had an man with chest pain and fluctuating consciousness. Since he was in a bad way, a few anaesthesiologists from ICU came to set up mechanical ventilation for the patient. It was really fantastic to see everyone working together almost seamlessly, and including me in their decision making. I was given little jobs such as getting supplies or checking the observations but it was all I could really help with at the time. After a very long trip to CT, it was clear our patient was deteriorating. As soon as he was back in resus, our patient went into cardiac arrest. The nurse I was working with asked if I had done CPR before, and if I wanted to get involved. To my own surprise, I agreed. I have been learning CPR for well over 5 years now, so I knew that I could help in some way. Each person did 2 minutes of CPR, whilst keeping an eye on the defib heart monitor. Due to the patient being on a hospital bed, we all had to stand on a stool in order to reach, which I found really bizarre!

I wish I could accurately describe the feeling of trying to save someone’s life, but I can’t. There was so much adrenaline rushing around me, but all I kept thinking about was how I was currently involved in the worst day of someone’s life.

During CPR, the doctors confirmed (through an echo-cardiogram) that there was nothing left we could do. Myself and the nurse went to work on ensuring our patient was at peace, and ready to be seen by his family. They were in shock and declined, which I understand. And our day went on. I had a debrief with the nurse, and a HCA who had also performed CPR for the first time, which was lovely. We spoke about how CPR is so different from how it is often portrayed. I had never thought about the fact that you won’t be able to reach a patient without standing on a stool, or how someone must time each session of CPR.

Despite being a high-pressure and sad situation, it helped me a lot. I did something I had never done, but had extensively prepared for. If you feel like you are back at square one, despite being a third year, I challenge you to think about what you do on placement. I think there is a tendency to see progression as acquiring new skills, but sometimes its about putting our current skills to use in a new situation.

 

 

Never ‘just’ a student

“I’m sorry, I’m just a student.”

Sound familiar? How many times have you said this while out on placement? Maybe it’s just me, but I’m ashamed to say it’s more often than I can count, especially in the first two years of my training. It possibly stems from a lack of confidence or uncertainty, perhaps a fear that I’d do or say something wrong – something we’re all bound to experience at some point during our training.

But is this lack of confidence a wider issue among qualified nurses, as well as students? Do we sometimes have a tendency, as a profession, to devalue our work and contribution? Do we see ourselves as less important or influential than other health professionals?

IMG_5369

Conference programme

I recently attended the 2017 Nursing and Midwifery Conference held by the newly formed Manchester Foundation Trust at Manchester Royal Infirmary. The keynote speech was given by Dr Eden Charles, a leadership coach and consultant who has been successfully supporting individuals to create cultural change in their organisations, including the NHS, for more than 30 years. He recognised that as nurses and midwives it is in our nature to give, to put others first and to sometimes put our own needs on the back burner. But, he said, with that sometimes comes a tendency to lack confidence in our huge strength and contribution as a profession. He said he often hears nurses refer to themselves as ‘just’ the nurse and is always baffled because of how important the role really is from the perspective of patients.

As student nurses or midwives, we are on the cusp of joining the largest professional body in the health service who are in a unique and privileged role as both care givers and advocates for patients. Although not yet registered, we are still an integral part of the nursing profession and make a difference in many ways to care in the NHS. The more confidently we value our contribution, the better we can speak out for our patients and give a voice to those who otherwise might not be heard.

In his speech, Dr Charles said: “Never say ‘I am just a nurse’. Change that story to ‘I am a professional nurse’. Put yourself into the world boldly and confidently as people who deserve to have a voice.” He challenged us to be ‘nursing rebels’ or ‘rebels for compassion’; to acknowledge our strength and abilities in order to gain greater influence and make changes to practice that really matter. He reminded us that leadership can be found at all levels, not just at the top; we all have a responsibility to bring about the changes we want to see. It’s not always easy or straightforward, but as students we can make positive changes by living the values that brought us to nursing or midwifery in the first place.

So I’m making a promise to myself and I hope you will too; I will never be ‘just the student’ or ‘just a nurse’ ever again.

Thriving, not just surviving: award-winning toolkit supports the mental health of student nurses and midwives in Manchester

image001 (1)

Tracy Claydon, PEF

As we highlighted earlier this week, Tuesday 10 October marked World Mental Health Day, an annual, global event recognising the impact of mental health on the lives of many and the importance of showing compassion to those struggling with mental ill heath, as well as looking after our own mental wellbeing. As student nurses and midwives, we may experience a broad range of mental health issues throughout our training as we adjust to our role; juggle placement, academic work and our personal lives; and because of the distressing experiences we may be exposed to on placement. Thankfully, the wonderful team of practice education facilitators (PEFs) at the newly formed Manchester Foundation Trust  (formerly CMFT) have our backs, creating an award-winning toolkit for mentors to enable them to better look out for and support our mental health in practice. We are delighted to share this Q&A with Tracy Claydon (pictured above), PEF for the Division of Specialist Medicine and the Corporate Division at Manchester Foundation Trust and project co-founder. She gives us an overview of the Mental Health and Wellbeing Toolkit and how it aims to support students and mentors in practice.

Firstly, what is the Mental Health and Wellbeing Toolkit?

We identified that there was no specific practical guidance to help mentors in supporting students who may be in emotional distress and/or be experiencing issues relating to their mental health when on placement; the Royal College of Psychiatrists’ (2011) indicated that as many as 29% of students may experience mental health difficulties at some point during their studies, while the National Union of Students (2015) have this figure as high as 78%. The toolkit was developed to support not only current nurses and mentors but also of course to support students to better manage the emotional demands of the role and feel supported to carry out their job confidently.

It is possible and also likely that a significant proportion of the students presenting in distress will not have a diagnosable mental illness but will be experiencing distress related to ‘life stresses’ and will need support to allow them to cope effectively with these rather than seeking to be prescribed an antidepressant or similar medication (NHS Choices, 2016). The provision of a toolkit that would provide a structure and framework for mentors to better support their students was clearly needed. The toolkit includes:

  • Tips for mentors including advice on how to discuss and identify concerns
  • Algorithms for accessing support
  • ‘Having the Initial Conversation’ guidance for mentors
  • Top Ten Tips for students to look after their own mental wellbeing
  • Agency Directory

The toolkit was launched in November 2016 and re-launched in May 2017 to coincide with World Mental Health Awareness Week which had a theme of ‘thriving or surviving’ which reinforced our message… we don’t just want our students to survive, we want them to thrive!

Where did the idea for the toolkit come from?

Students will often experience quite harrowing situations during one single placement that possibly other members of the public will go through their entire lives without seeing.

We talk often about resilience, but how do we build this? And crucially, what can we do when anxiety becomes more than a transient emotion? From a practical guidance we recognised that there were gaps in our support mechanisms within the organisation and also that we had the underpinning literature to evidence this.

The Nursing & Midwifery Council and the Royal College of Nursing recognise the potential for students to experience difficulties in their mental health and yet surprisingly neither agency has/had provided any guidance for nurses or mentors to support them.

At Manchester Foundation Trust (MFT) we wanted to fill this gap and the toolkit was developed as a resource to address this. Equally, it was also incumbent upon us to acknowledge how anxiety or a sense of isolation when not managed in the early stages can then escalate into something more concerning.

The goal was to support our students at the beginning, end and at all points in between on their placement and learning journey, so that they will recognise and regard MFT as a caring and compassionate organisation that enables students to thrive and not just survive and that they would wish to return as qualified staff.

How did you go about developing the toolkit?

download

Ant Southin, Specialist Mental Health Liason Nurse

It came as a result of a real life situation where I as a PEF was supporting a compassionate and kind mentor who was struggling to support a student on placement struggling with mental health issues. Myself and my PEF colleague Sharon Green, began working on the toolkit as a resource however, the toolkit only truly started to develop when we were able to access the knowledge and skills of Specialist Mental Health Liaison Nurse, Ant Southin (based at MRI, pictured right) who was able to provide the expertise that we as registered adult nurses by background lacked. This enabled it to have a real MDT approach and became a wonderful collaboration!

How has the toolkit been used in practice so far?

For some students the situations they observe or are involved in will be the most distressing thing they have experienced. It is important that they have a means of communicating and understanding these feelings and recognising that there is help available. The Toolkit has been used in a number of situations where students were struggling to cope emotionally: including supporting students who were affected by this year’s Manchester Bombing.

What are your plans for the future of the project?

Despite having been awarded the MRI Fellowship Award at the recent Nursing and Midwifery Conference and also having been acknowledged as an example of Best practice by Health Education North West (available as an E-Win) we feel this work is still in its infancy; while it is currently aimed at students, we recognise that the messages are important for all of our staff. We hope that we can develop it to be used to support any member of staff experiencing distress. The Human Resources department have requested a meeting to begin discussions around achieving this within the wider organisation. We will be presenting at the upcoming Midwifery Forum at St. Mary’s Hospital and we have also had heard nationally from other NHS Trusts interested in adopting the toolkit within their own organisations.

The MRI Fellowship Award 2017 included a £1000 monetary prize which will be used to support ward areas to develop their own ‘buddy box / soothe box’ resource which they can then continue to develop to meet the needs of their students and staff.

…and finally, what advice would you give to student nurses and midwives to take care of our mental health while on placement?

Student nurses and midwives need to feel prepared and supported for the career they are about to embark upon. The profession is challenging and demanding but with huge personal and professional rewards. Mental health issues can affect any of us at any time in our careers and should be considered a priority for all of us whatever stage of our career we are at. By making them a priority for students it is hoped that they will continue to see this as a priority as they progress through what we hope will be successful nursing/midwifery careers. Using our dedicated #icareforme approach we will continue to maintain the profile of the huge importance of self-compassion for staff working within such challenging and complex environments. It is vital that mental health has the same parity with physical health and we can only achieve this by making it the priority it deserves and needs to be.

Thank you Tracy!! If you’re interested in learning more about the toolkit, you can find it here – in particular, take a look at the ‘Top Ten Tips for Good Mental Health’ on pages 8-9 for simple ideas that we can all use to look after our mental health.

Remember that if you are struggling with your mental health or feeling anxious, worried or depressed then don’t try and suffer on in silence. If you feel confident to do so, speak to your mentor, PEF or academic advisor (AA) or the University of Manchester has a fantastic confidential Counselling Service. Often speaking with your peers can ease the burden – you may find that others are feeling the same – or if you simply want a kind, listening ear then Nightline is another brilliant option, you can find the contact number on the back of your student card.

World Mental Health Day 2017

World Mental Health Day, founded by the World Federation for Mental Health, takes place each year on 10th October and adopts a different theme each time. The aim is to raise awareness about mental health and encourage people to think about ways to support those who are experiencing mental health conditions. This year the focus is on mental health in the workplace.

imageThe World Health Organisation discussed how depression and anxiety disorders are common and can have an impact upon a person’s work life. Stress is a major factor that contributes towards the development of mental health conditions. With increased demand, funding cuts and staff shortages, there is no doubt that nurses and healthcare services in general are under immense stress. Nurses working in hospitals are said to be twice as likely as the general population to have depression.

For some mental health nursing students, having lived experience of depression and/or anxiety is a big part of what motivated us to choose to study for a degree in this field of nursing. Personally I chose this career because of the platform it can hopefully give me to help improve mental health services that I was involved with when I was an adolescent and to promote awareness of mental health using not just personal experience but professional knowledge too.

image

Not many health professionals speak out about their experiences of living with mental health conditions through fear of having their capability to support other people doubted. Mental health conditions affect people in the workplace, and healthcare settings are no exception. To reduce the impacts of stress and workplace pressures on mental health it is important for people be aware of the support services available for employees. The NHS Services Directory is a useful tool for locating local places where psychological therapies can be accessed. Offering support can be as simple as asking a colleague how they’re feeling. If we start conversations, we’re closer to ending the stigma.

Balancing the Bank: Things I’ve learnt as a bank HCA, by Caitlin Mitchell

Joining the bank or an agency as a Healthcare Assistant is probably something you’ve already considered if you, like many of the rest of us student nurses, are a little low on funds! You’ve probably already considered the pros and cons of joining the bank over a non-healthcare part-time job but I wanted to share some of the reasons why I’ve loved banking as a HCA, and what I’ve learnt from it …

caitlin

 

Exposure to other services/areas of the hospital

I am now able to confidently signpost patients to these services. I’ve also been able to use it as an opportunity to make contacts with other professionals and was able to arrange some interesting spoke opportunities from it! It’s great for networking and if you’re considering a job on a particular ward after graduation you can always go and scope them out by booking a few shifts there! Having first hand experience of the ward and a good first impression with future colleagues on shift can also give you an edge over other candidates in the interview!

Providing personal care

I found this quite daunting when I started the course due to not coming from a hospital background but having the chance to work with HCAs whilst banking helped me feel more confident with what I was doing, and also impress the HCAs I later met on placement!

Communication 

6cs

I improved my communication with non-verbal (due to having tracheostomies) and deaf patients. I initially found this challenging but spending large amounts of time with these patients, delivering the bulk of their personal care helped us learn to communicate with each other and we even managed to share a few jokes! I found that patients and relatives were often all too happy to share how they like to communicate and even taught me some sign language!

My best advice if you don’t know sign language is to start by speaking slowly to allow the patient to lip read if they can and build up from there. This may seem like obvious advice but if it’s been a busy shift it can be easy to forget and speak too quickly before rushing off to the next task, remember to wait until you have eye contact with the patient before speaking, if deaf or hard of hearing they may not have heard you enter the room so wait until you have their attention before you begin! I also really recommend following @BritishSignBSL on twitter because they post a new sign each day, you can also download and print the finger spelling alphabet from their website!

Decision-making and autonomy

I felt that, on certain wards, I was trusted more to get on with certain care tasks than I was as a student. Whilst this was a confidence boost, I was also reminded of the importance of asking for help if I didn’t feel confident doing something on my own, and of working within the limits of my job role.

Delegation

I feel that my delegation skills improved through banking as I was reminded of the importance of checking that the person you are delegating to feels confident with the task, and the importance of thanking someone who has helped you with a task!

Time-management

fob watchIt almost goes without saying that balancing a part-time job on top of uni work and placement requires top notch time-management skills. To help with this I would recommend investing in a decent planner if you’re going to be splitting your time between uni, placement, a part-time job, and any other hobbies/socialising in order to know where you need to be and when! This all lends itself beautifully to a colour-coding system!

If you’re struggling around exam/deadline season, the beauty of bank work is that you can book shifts as and when suits you, so if you need to take some time to concentrate on your studies you’re not tied down to committing to certain hours and then you can pick more shifts up outside of term time as it suits you. Being able to balance time effectively is an important nursing skill and I was able to use this as evidence of this skill at my staff nurse interviews!

I hope that some of these points have helped give some of you an insight into the benefits of bank/agency work!

Sexual health healing: my elective placement in a GUM clinic

People coming to sexual health services experience a wide range of emotions; from embarrassment and fear to shame, guilt and anxiety. Sexual health carries with it some serious baggage and stigma that other areas of health don’t, but why is that? We wouldn’t think twice about going to the doctors for other health conditions, yet for some reason feel like we need to sneak in to sexual health clinics cloak and dagger, desperately hoping that we won’t be recognised. Sex is one of the most normal and natural things imaginable and anyone taking proactive steps to look after their sexual health should be celebrated…yet it is an area of health that many still find embarrassing or taboo.

This summer I completed a seven week placement in a sexual health clinic. I was excited to start as I’d always been interested in sexual health, but I must admit I was also a little nervous. Discussing sex openly and frankly can sometimes be just as intimidating for the healthcare professional as the patient – especially for an inexperienced student nurse still finding her feet! I’d be lying if I didn’t say I had the odd awkward moment over the placement – I struggle to hide my emotions and definitely felt my cheeks blush on the odd occasion during my first few solo interviews – but I soon realised that patients took their cues from me and the more relaxed I was, the more at ease they seemed. Before too long I was discussing STIs and sexual preferences as casually as the weather or what they had for tea last night. It was rewarding though, seeing people arrive at the clinic looking nervous, upset or worried and leave, free condoms in-hand, looking relieved and reassured. Along the way I also learnt a thing or two about the broad skills and expertise of sexual health nurses. Here is what I learned:

They can keep a secret

Confidentiality is one of the fundamental principles of sexual medicine. All staff working in sexual health, from consultants to student nurses, must sign a confidentiality agreement on entering the department. Of course this principle applies across all areas of healthcare, but it is particularly precious in sexual medicine where a patient’s right to privacy is central. Patients are not obliged to give their real name or date of birth when accessing sexual health services, nor will you hear a nurse calling people in the waiting room by their full name. Patient notes are also kept completely separate to other systems in the NHS and information will not be passed to services like GPs without consent or unless absolutely necessary. Explaining this to patients at the start of their appointment is often a good basis for gaining their trust and confidence.

They are expert communicators

Specialist sexual health and HIV nurses are incredibly skilled in taking detailed histories, asking the most personal questions imaginable, while remaining non-judgemental. Those questions can seem extremely intrusive and many people wonder why they need to share details of foreign partners, drug-taking or exactly what type of sex they had, so it takes a highly-skilled communicator to gather this information in a matter-of-fact, caring and non-judgmental way. As the interview unfolds, you can sometimes visibly see people recoil at the questions – in the cold light of day, sitting in a clinical room opposite someone in a uniform asking you about some of the most intimate parts of your life can be extremely difficult. Sexual health nurses completely understand that; they want to make the process as painless as possible, so will adopt many different communication strategies to put their patients at ease.

They know their stuff

The majority of sexual health and HIV nurses are specialists, with many years of experience and additional qualifications or training in sexual medicine. While in the past nurses in sexual health clinics would have assisted the doctors, they now work autonomously, often in nurse-led clinics. Nurses are the backbone of gentio-urinary medicine (GUM) clinics, working closely with consultants and experienced healthcare technicians. It’s a highly-skilled role that requires in-depth knowledge of sexual health conditions including their symptoms, methods of diagnosis and the latest evidence-based treatments, some of which they are now able to prescribe themselves under Patient Group Directives (PGDs). They work hand-in-hand with the doctors, undertaking the same assessments and doing the same tests and examinations. They also tend to be the clinicians delivering the treatments, from antibiotics or deep IM injections to wart freezing. They can do the whole lot.

They are un-shockable

Believe me, they have heard and seen it all. They are not there to judge your sexual behaviour and they don’t. They ask such personal questions because they want to make sure they carry out the most relevant tests, ensuring that they pick up any potential sexually transmitted infections (STI) someone could have been exposed to. Knowing whether someone has had foreign sexual parters or taken drugs, for example, can influence whether they decide to add in blood tests for hepatitis B and C. It pays to be as honest and frank as possible because it means that they do the full range of relevant tests.

They care about your physical AND mental health

WHO define sexual health as both absence of disease and healthy attitude towards sex. Sexual health nurses aren’t just concerned with detecting and treating STIs and giving out free condoms; they also play a therapeutic role, helping to ease anxieties and educate individuals about safe sex.  They can play a big part in helping someone overcome a bad sexual experience, often taking on a support and counselling role, especially nurses who choose to be sexual health advisors. Even for patinets who don’t specifically open up about their worries, you can see how a skilled sexual health nurse can make someone feel better just by being kind and matter-of-fact. Conditions like HIV of course sadly come with some of the greatest stigma and potential to impact mental health. HIV specialist nurses therefore are key in helping people come to terms with their diagnosis and cope with the wide range of emotions they may experience. They are often the first port of call for patients, sometimes being the only person that a patient has disclosed their HIV status to and feel comfortable phoning up to discuss worries and fears. As well as managing and monitoring their treatment HIV specialist nurses often become a trusted confidant, helping individuals to regain their confidence and self-worth or access local networks where they can access peer-support.

All-in-all, my placement in a sexual health clinic revealed the nursing role to be fascinating and rewarding. Sexual health nurses are a down-to-earth bunch who come into contact with people from all walks of life and use a broad range of advanced nursing skills to make a positive impact on physical and mental health. There’s a lot more to it than giving out free condoms, that’s for sure!

If you’re interested in sexual health, there are some brilliant websites out there. The British Association for Sexual Health and HIV (BASHH) guidelines for example share evidence-based clinical guidance for diagnosis and treatment of STIs. There are also some fantastic Manchester-based charities and organisations with a focus on improving sexual health such as Manchester Action on Street Health (MASH), a charity supporting women engaged with sex-work in Manchester; George House Trust, a charity supporting people living with HIV; LGBT Foundation, who offer sexual health testing for LGBT communities among many other services; and Sexpression Manchester a student-led organisation that offers informal sex and relationship training for young people.

Do you have an experience or reflection from placement that you would like to share with other student nurses and midwives? We think every student nurse or midwife has a unique and interesting perspective to offer so we are always keen to welcome new student bloggers to our team. If you have a story to share please do get in touch via our Facebook page @UoMPlacementProject or email studentnurseplacementproject@gmail.com.