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.

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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.

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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 

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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!

Pearls of wisdom from the 2016 graduates!

It was great to meet so many of the third years at today’s employability conference and to the new cohort of first years a very warm welcome! We’ve been asking some of the BNurs 2016 graduates what they’ve been up to since graduation to help give you some inspiration, careers & studying advice and some reassurance that there is light at the end of the tunnel!


 

Gina, Chemotherapy Nurse.

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I work on a nurse led chemotherapy unit, one of the most interesting things about my job is being able to assess patients and use my own clinical judgement in providing holistic care. Rather than task oriented nursing, you’re able to work more autonomously but there’s still a lot of support available from the rest of the team. We see patients from a variety of different disease groups with different chemotherapy and immunotherapy regimes so there’s been a lot to learn over this first year! There’s also exposure to higher acuity patients and oncological emergencies so there’s a variety of clinical skills.

I’d advise current final year students not to underestimate the benefits of a good preceptorship programme! Ask about what support and training trusts can offer you as a newly qualified member of staff and it’s also worth looking at how they score on recent CQC reports. Always have a few questions prepared to ask at the end of an interview to show your interest in the role and it’s well worth organising an informal visit or arranging a phone call with the ward manager to find out more information. They’ll remember you and if offered an interview you’ll have an advantage over other candidates who didn’t show the initiative!

For first years at the start of their nursing journey, make the most of what your placements have to offer and get involved with sports and societies while you’re at uni, sometime it can feel like a struggle to balance everything but it’s important to have variety and these things will help you unwind after a hectic shift! Always show interest on placements and ask lots of questions, make sure to go to your PEF or AA with any issues and they can support you through it and improve the placement for other students in the future.21952670_10155829453445820_863942415_o

One of my proudest achievements so far was presenting a piece of research I did at the RCN Centenary conference, it was quite daunting being a student at an international research conference but I’d definitely recommend applying for things like this, there’s so many amazing opportunities out there! I’m definitely interested in research career options for the future but I also enjoy the clinical side of nursing, I don’t have any set goals for the future as there’s so many fantastic career paths out there but I’m quite interested in becoming a nurse prescriber, I’ll just have to wait and see what pans out!

Chris, Cardiology Nurse.

The most interesting thing about my job is the procedures and interventions carried out on patients. I’m currently working towards mentorship and a link nurse role and in the long term a specialist nurse role. For current third years job hunting; choose an area you find interesting to work in (for myself it was cardiology). Ensure when you prepare to interview you show your passion or interest for that speciality or area. Demonstrate your knowledge!

Some advice for first year students would be, don’t be shy. Ask lots of questions and get stuck in as much as possible when on placement. I wish I had known more abbreviations of medical terms. Advice for final year students, get on top of your dissertation early. I can’t stress this enough!

Emily, RMN on a Psychiatric Intensive Care Unit.

I chose this job because I wanted a fast paced ward and it’s certainly that! It’s really interesting to see people come in very poorly but go back to acute wards much better. I see myself staying on this ward for the next 2 years or so, then hopefully moving into forensic services.

Some advice for third years’ looking for jobs is to go for something you know interests you, you’ll enjoy going to work then. Research the ward and trust before the interview, they’ll most likely ask you for evidence/scenarios to back up your answers.

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Also, take time for yourself!! Although the course is full on you need to make sure you look after yourself, take the time to do it now because you won’t get it when you start work! Take it as it comes, get ahead with your dissertation, DON’T leave it until last minute. You will have enough stress in your final few months. And finally, enjoy your training, don’t let it get on top of you. It will go by quickly!

Liz, Staff Nurse on a General Surgical ward.

Something I wish I’d known when you started the course? I remember everyone complaining (including myself) how we felt like we only did obs for the first placement. This is an important skill the more you do the more efficient you become and the better you get at recognising deteriorating patients early!

Advice for current third years deciding where to work: Go to every interview you get offered they are good practice! And then if you get offered lots of jobs you have more choice.If you feel like it’s impossible or you don’t feel ready. You are ready and you can do this! There will come a time on your final placement when you wish you didn’t have to check the drug round e.t.c with someone every time. That’s when I realised I couldn’t wait to qualify!

I’m enjoying my new role, it’s very diverse and I get to use and perfect every clinical skill I could wish for, in a first job. In the future, I see myself working in the merchant navy and also on the bank in an NHS hospital. Moving from student to staff nurse is the most challenging and fun time. Enjoy it and remember to be nice to the students who, before you know it, will be your mentees!

Natalie, Surgical Triage Nurse.

I chose this area as I love Surgery and wanted to gain experience in Acute illness, emergency surgery and different surgical conditions not just one speciality.

Enjoy student life whilst you can as 2nd and 3rd year are intense. Spoke out as much as you can and make the most of the supernumerary status to learn. Make sure your work/placement/study/social life is well balanced. Seek advice where necessary.

Some interview tips for third years is to learn about policies in your chosen field, memorise the 6C’s,  and look at recent CQC reports to draw on points for why you chose their hospital/department.

Alyssa, Community Staff Nurse.

whitworth hallI am a community staff nurse, nursing patients with long term health conditions. The patients whom I care for can be under my care for years. The care that I deliver enables you to build a very strong therapeutic relationship with patients that you wouldn’t necessarily get in a hospital environment. In the future I see myself working in the community, hopefully as a district nurse.

Some tips for first years would be to follow your passion. Find something that you love and run with It! For me, that was community nursing. If you do what you love, this will show in the excellent care you give to your wonderful patients!

And for third years preparing for interviews; do lots of research about the trust you want to work at e.g. core values of the trust and the person specification for the role which you’re applying for. Phone your prospective ward prior to the interview and ask for an informal visit to get a feel for the ward/department.

Third year is tough. There will be a lot of blood sweat and tears during your final 12 months, but there is a light at the end of the tunnel and if you work hard you’ll soon be wondering where your final year went! Your hard work and pure determination will pay off. Your patients will make you feel so blessed every day and I promise all your stress and worry is 1000% worth It!

Donna, ICU Nurse.

What made you choose this speciality to work in? What’s the most interesting thing about your role? I wanted to work in a dynamic and interesting area, seeing lots of different ailments and issues that people come into hospital with. I love being 1 to 1 with my patients and able to give all patient cares, being 100% involved. I get to be very involved in the patient journey and plans for their care and my opinions are respected and listened too.

Some tips for 1st year students, don’t leave everything til the last minute! 3 years might seem like a long time, but it flies by! In placement, there is something to be learnt in every situation that will develop you as a nurse and make you a safe but above all, caring practitioner.

Final year students, don’t get too wrapped up on knowing everything, no one expects you to know what you are doing when you qualify! You will get training and helped along the way by your peers! Enjoy your last few moments of student life, it’ll be over before you know it! Be proud of yourselves!

Placements aren’t the be all and end all. I did not have a placement in critical care, but still managed to get my dream job. Never let someone tell you that you can’t do it! If I can, anyone can. Whether you’re in the final phase or are just at the beginning of this journey, you have achieved something wonderful to come into this profession, especially at such an unstable time. I wish you all the best with your future endeavours, whatever they may be.

My proudest achievement so far is being able to actively be involved with my patients journey and care plan! When you start out as a fresh eyed newly qualified nurse you feel like a fish out of water, especially in such a highly specialist area as critical care! To be able to see yourself develop and be able to suggest or question a care plan with enough knowledge to back it up is a huge achievement. In the future, I’d like to progress in my role, maybe into a band 6? Who knows. But for now i’m happy to learn my specialisation and will start a level 7 course in critical care next year and begin my mentorship course!

Victoria, Critical Care Nurse in ICU & HDU.

The fast pace and quick thinking, variety of conditions I come across and complexity in illness, continuation of learning and developing new and old skills and knowledge, problem solving and the use of all my nursing skills attracted me to working in this speciality.

Some tips tips for 1st year students are to always ask and never be afraid to ask for help at any time..nurses are more willing yo help than you think, always reflect on your day it will help you throughout your career. If things get a bit too overwhelming stop, make sure you patient is safe and remove yourself from the situation and take a breather.
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I’d advise third years to do what you enjoy because you’ll be passionate in providing great care to your patient. Relax and be yourself…yes, you are being interviewed, but so are your possible employers, so always go armed with questions yourself. Be organised and try to stay on to of your work. Time management is very important.

My proudest achievement so far is getting awarded a first class degree and getting the opportunities to carry on my learning to help others. In the future I’d see myself being an experienced critical care nurse and mentoring and supporting other newly qualified staff in the area to be fantastic nurses.

Enjoy every moment of your university time and career, the hard work will pay off and if you enjoy what you do it will translate in your work and the care you give your patients. Always smile, a smile goes along way and is noticed by all, patients included!

Holly, Staff Nurse in A&E.

Initially I wasn’t sure where to work and A&E provides such a variety of conditions. The most interesting part of my job is providing life saving care in resus. I want to work in A&E for a couple of years to build on my skills and confidence, but I’ve not thought past that yet!

For job hunting in third year, don’t stress about it! If you are a last minute kind of person, like myself, and your friends have all got a job lined up by December of 3rd year don’t let it panic you, I didn’t apply for jobs until the end of summer of 3rd year and still got a job well before graduation! Start the dissertation early, don’t leave it all till the last minute like I did, trust me it’s not worth the stress!

My proudest achievement so far is getting a first class degree, never thought it would happen but hard work definitely pays off. I was a mature student and found the financial side of being a student very difficult, going from working with a full time wage to do 4 years of study (I did the access course & degree) was a difficult decision and I can only imagine how hard it was for my colleagues with children, but it is so worth it. If you’re having a rough time at uni and really struggling, I used to think about my first months wages and think about what I’d treat myself to…only afforded something little after bills were paid but that felt amazing. Keep at it, 3 years seems like a long time but it goes so fast then you have a fulfilling career ahead of you.

Ellie, Mental Health Nurse in Acute CAMHS.

I chose this speciality as I really enjoy working with young people, it’s challenging at times working in an acute environment but really rewarding and enjoyable too.

I’m currently working towards becoming a student mentor as I’m still at a point where I remember how it felt to be a student, and also what it was like to have a bad mentor. I love working with students now. In the future I can see myself training to be a nurse therapist.whitworth hall (2)

Some advice for first years would be that confidence will come in time. Every skill the nurses have they learned somewhere, you can be a great nurse if you stick with it.
For current third years deciding where to work, don’t be disheartened by everyone else saying they have jobs (there’s lots of quiet people who don’t)! I felt like I was one of the last ones to get a job and I ended up getting one in my ideal speciality – it made me glad I got rejected for the ones I wasn’t actually too fussed about!

Do I have any advice for current students on managing their final year? It ends! Joking aside, it really does. You’ve got this guys. Honestly, finishing a nursing course at University of Manchester is one of my proudest achievements so far. It is genuinely one of the most academically rigorous courses out there.

Nina, Paediatric A&E Nurse.

I loved A&E since my third year placement.  The most interesting thing about my job is that I work in a major trauma centre in London and get to see a wide range for illnesses and injuries. In the future I can see myself doing a management role or being an Advanced Nurse Practitioner.

Some advice for new students would be to get stuck in with placement! Take opportunities and involve yourself. For current third years deciding where to work; pick somewhere you have a passion for or want to learn more about!

Julia, Community Dementia Nurse.

grad bannerPersonal experiences made me want to work in elderly and dementia care, I felt I had a basic understanding of what a patients family are going through and help me to support them better.

I’d advise current students to speak up on placement and be questioning… ask why was this or that done a certain way whilst on placement. For third years job hunting, go with something you feel slightly confident with. For managing your final year, stay organised till dissertation is done! Don’t be afraid to start from scratch again if needed.

My proudest achievement so far is making patients smile and getting thank you cards from families I’ve helped. In the future I see myself doing exactly what I’m doing now! Just more knowledgeable at it!

You never stop learning, transition isn’t that bad, but remember you are accountable which is scary but don’t let that stop you from holding hands up if something goes wrong. Support is out there. You learn from your mistakes.


If you graduated from the UoM BNurs cohort in 2016 and want to contribute your experiences of your first year since qualifying to this article please use the contact form below.

Likewise if you’re a current student and want to get involved with the placement peer support project or write a guest post on a particular placement or topic that interests you, please drop us a line! We’d love to hear from you!

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Enabling quality of life in very difficult circumstances, by Kate Plant

19964730_1773600412654889_568888045_nA thought provoking guest blog, second year CYP student nurse Kate Plant shares her experiences and insights into palliative care from her DILP summer placement…


Before starting my nursing degree, I volunteered as a Sibling Support Worker at my local Children’s Hospice. So, I already had some idea about how special these places are. But it was not until I undertook my Elective Placement there that I realised how rewarding a nursing role, in the provision of Palliative Care, can be.

The first thing I noticed was the difference in pace, compared to my previous placements. I was used to dashing around on hospital wards and barely having a moment to drink. So, when I was offered a cup of tea on my first day (half an hour into my shift) I was completely taken aback. But, obviously, there were more significant differences than having the time to quench my thirst. A patient would be allocated both a nurse and a care support worker, on a 2:1 basis, due to the complexity of the patient’s needs. This 2:1 care gave nurses time to listen and understand what really matters to the patient and their family. There was no rushing around. The environment was relaxed. Families would allow a nurse and other staff members to enter their lives in very difficult circumstances and build strong relationships with them. This is where the satisfaction came in.

CYPIn addition, I have by no means observed doctors, nurses and care support workers work together as well as within palliative care. There was no division but instead, a sense of unity. This enabled a pleasant atmosphere to bloom within a setting which, stereotypically, has connotations of being constantly surrounded by upsetting situations. All staff members were part of a team, encouraging a family atmosphere so families were as comfortable and happy as possible. Staff were able to take away a families’ everyday stresses so children and their families could treasure the remaining time they have together as a family, however long this may be.

The thing that struck me the most was the parent’s enormous strength to keep a pleasant face for their terminally-ill child and their other children, in one of the hardest times they can ever face. A parent’s strength is aided through their ability to effectively plan, with help from compassionate and empathetic staff members, any wishes they have in the care their child receives before death. This includes preferred place of care, spiritual and cultural wishes and anticipatory symptom management planning.  With such a wide array of resources available at the hospice (including sensory rooms, adapted garden swings, music rooms, parent bedrooms, bereavement rooms – the list could go on and on) these wishes were almost always met.

TOGETHER_LIVES_RESIZE_800_450_90_s_c1_c_cLast year, the ‘Together for Short Lives’ charity reported a national shortage of children’s palliative care nurses which is negatively impacting on the care provided to children and families. I truly believe if other students and qualified nurses were to gain a deeper understanding and/or even experience how rewarding roles in Palliative Care can be, this could help bridge the care gap. After all, you’ll never regret making a difference in the quality of care a child or young person received, during their last moments of life.

‘Tools of the Trade’: Adult Field

Preparing for your first placement and feeling uncertain about what assessment tools you might encounter? Have a browse through this post where we’ve collated some assessment tools and tips you might find useful, with links to the sources in the title. If you’ve not seen it already, you can also find some useful information in our top tips album on our Facebook page. Have a look at the Mental Health tips and tools here, Child Field and Midwifery specific posts to follow soon!

Below are a selection of assessment tools in alphabetical order, remember that all risk assessment scoring tools are simplified to some extent and scoring may be subjective. Therefore it’s important to use them in the correct setting alongside your own clinical judgement, never underestimate your gut feeling and if you have any concerns about a patient, speak up!


Bristol Stool Chart

Also known as the Meyers scale, the pictures and descriptions on the Bristol stool chart will help you assess stool samples. Stool charts are often in place if a patient is being barrier nursed with infective diarrhoea. Colour, presence of blood or mucus are also important things to look out for when assessing stool samples.

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ECOG Performance Status Score

Used in 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

Frailty Assessment

There are many different tools used to assess frailty, but the PRISMA 7 checklist below is perhaps the easiest to use as an informal prompt to identify at risk patients. It has been used in a variety of research studies on frailty to identify disability, a score of >3 indicates frailty.

1- Older than 85 years?
2- Male?
3- Any health problems which limit ADLs?
4- Requiring help on a daily/regular basis?

5- Housebound due to health conditions?
6- In case of need can they count on someone close to them?
7- Regular use of a stick, walker, wheelchair or other aids to get about? 

Other red flags to look out for include is a patient lives alone or if they are a carer for another person. Frailty can impact on discharge planning and is useful to consider when planning interventions to avoid future hospital admissions. There are also other useful resources and information from Age UK and the British Geriatrics Society.

Glasgow Coma Scale (GCS)

GCS is used to assess a patients consciousness level, primarily in acute areas such as A&E or ICU. Assessing a patient’s GCS can be complex and involves three categories: eye opening, verbal response and best motor response. After checking for factors that might impede the patient’s ability to respond, each of the three criteria are assessed through observation and stimulus and are then rated according to the highest observed response. Unless you’re working in a placement are which uses the GCS assessment frequently where you can be taught how to use it correctly, it’s probably best to use an alternative.

AVPU is a similar tool to rapidly and simply assess your patient, it is based on the same three categories as the GCS and looks for the best response, working down from best to worst A-U to avoid unnecessary tests.

A- Alert
V- Alert to Voice
P- Alert to Pain
U- Unconscious 

If a patient is fully awake and can spontaneously open their eyes and has control of motor function they are Alert, although they do not necessarily have to be orientated. Patients who are alert to Voice will make some form of response in any of the three categories when you speak to them. If alert to Pain, a patient with some level of consciousness will respond to painful stimuli with any of the same categories of response and fully unconscious patients will form any response to any of the above.

Early Warning Score (EWS)

In practice you may come across some variations of the EWS (Paediatric (PEWS), Modified (MEWS), National (NEWS) and Modified Early Obstetric Warning Score (MEOWS)), for this reason the scores and corresponding clinical observations haven’t been included in this post.

Ensure you use the tool that has been selected for use in your clinical area as there are variations between them according to specific patient type or to support best evidence based practice. To begin with don’t worry about remembering the exact scores for each observation, the scores are printed on observation charts and care plans, all you need to recognise is when observations are abnormal and escalate it.

When taking a full set of observations, a score is given based on how far they deviate from a normal baseline. These are then added together to produce an overall score. The higher the score, the more severe the level of clinical deterioration. Research has shown that scores of 5 of higher are linked to increased ICU admission and mortality.

The idea behind EWS is that a deterioration will be flagged up by a score which can then be acted on before the patient deteriorates further. However in practice a patient may go off quickly where their previous score may have been within the normal parameters, be wary when a patient’s overall score may well be zero but when charted you notice that their observations are borderline and if one figure higher would then begin to score. In situations like this it may be prudent to recheck their obs to ensure a correct reading or to increase the frequency of repeating their observations.

It’s also wise not to underestimate the importance of using your clinical judgement in conjunction with good communication with your patient. For instance, don’t dismiss a “feeling of impending doom” reported by your patient, it can have high clinical significance. As before, if you have any concerns about a patient, make sure you escalate them to a member of staff.

The Malnutrition Universal Screening tool (MUST)

MUST is an accredited screening tool from the British Association of Parenteral and Enteral Nutrition (BAPEN), whose aim is to improve management and understanding of malnutrition.

You can use this tool to obtain a score and risk category for the patient and create an action plan. A MUST assessment is generally completed on admission to any inpatient area and for low risk patients is usually repeated weekly. For patients with a higher risk of weight loss and malnutrition this is reassessed more frequently according to level of risk to check the efficacy of any interventions that have been implemented.

To help you complete a MUST assessment, you can find the NHS BMI calculator here and the metric-imperial conversion chart is below.

Waterlow Scale

Developed by Judy Waterlow, a clinical nurse teacher, in the 1980s; the Waterlow scale is used to assess the risk of pressure damage or pressure ulcers forming. These ulcers are formed through pressure, friction or shearing forces; usually on prominent bony surfaces causing damage to the underlying tissue and skin.

Once formed, pressure ulcers can be very problematic to treat and slow to heal so prevention is better than cure! Good manual handling technique to avoid friction and shearing and regular turning for pressure relief and/or use of mattress aids is key to avoiding ulcer formation.

The tool below shows scoring tables for different risk categories to create and overall score. Special risks for consideration are shown in the pink box, such as time spent immobile on an operating table or neurological conditions affecting mobility and therefore patients’ own ability for independent pressure relief.

waterlow score card

To understand more about pressure ulcers you may want to consider a spoke with the Tissue Viability nurses, most wards will also have a tissue viability link nurse who you could speak to.

 

Documentation: key things to consider when writing in patients’ records

Documentation word cloud

When you document in patient notes it’s important you keep things clear and accurate; they should be an honest and timely objective record. Avoid personal language and subjective commentary, the notes should be appropriate and non-discriminatory. Remember it’s a legal and professional document and bear in mind that your patient might read them one day.

It may seem daunting at first and your approach or documentation style may vary between different placement areas but hopefully these tips may help you understand what is expected when you’re asked to document your shift and make sure you check the documentation and records keeping policy at the trust you are based at.

dr handwriting

Ensure you keep your handwriting legible if writing handwritten notes! If you’re typing up electronic records make sure you have spelt everything correctly, beware of any spellcheck programs that may auto-correct any medical terminology they do not recognise.

Electronic records systems will automatically produce a time stamp and will record the name of the person logged in as the author of that note. If you’re handwriting notes you will need to do this by hand and include the date and time for each entry and end with your name, designation and signature. If you need to add anything, add this on a line below and sign next to it. If you need to add or amend any computerised notes, some programs will allow you to log back in and edit the record within a certain time frame of the entry. If not, just simply add a new entry detailing the addition or amendment you want to include.

If you’re editing any paper documentation remember not to use tippex, just use a single line to strike through the text and sign next to it. It’s also good practice to use a line to strike through any blank space on a line at the end of a sentence so nothing can be added in later. You’ll need to make sure your mentor or the registered nurse working with you on that shift also countersigns your documentation.

abbreviations

Although your handover sheet is probably littered with abbreviations like a secret code, it’s best to avoid them when you’re writing up notes unless they are from an approved list. The meaning of some abbreviations may vary between trusts or specialities and may cause confusion if the meaning isn’t clear!

In terms of format and content, it’s really up to you!  Some people prefer to write up the shift chronologically whereas others use an A-E based format or to divide content by body system. For more tips and ideas have a look at Heather’s post here on writing in patient notes.

You may also wish to include any patient contributions to their own care or any significant remarks from them during the shift if relevant. If you do feel that something is significant, for example if a patient has a concern or if you notice a deterioration in their observations or anything else worrying you, make sure you escalate it by reporting things to your mentor or the nurse you are working with first, then you can record it afterwards.

You can find some other resources on documentation here:

 

 

Patients aren’t Specimens!

I don’t know if many of you watched Call the Midwife this week (massive fan #sorrynotsorry) but part of it really resonated with me. I can’t comment on the accuracy of the actual midwifery, I’ll have to leave that one to our resident student midwife bloggers, but there was one scene that really stood out as a fantastic example of patient advocacy.

In the episode a woman and her partner, both with achondroplasia, are expecting their first child. We see her anxiously awaiting a Caesarean section as she goes into early labour. On the ward prior to surgery the surgeon discusses her case bluntly in front of her to a crowd of medical students, speaking about her as if she wasn’t there. Later on in the episode we see her again with her new baby (after plenty of dramatic tension!), this time the doctor leads the ward round of students in but the nurse steps in and stops him with “Mrs Reed is not a specimen, she’s a mother”.

Sometimes on placement you may see staff refer to patients as “Bed 11”, “The side room”, or “The hip replacement”, just to give a few examples. We’re no longer in the 1950s so there’s really no excuse for patriarchal attitudes in healthcare! If you want to observe a procedure, always introduce yourself to the patient and ask their permission. Ensure your request is worded so there’s no pressure on them to agree and if your mentor or another nurse is asking for the patient’s consent on your behalf it’s sometimes better if you wait elsewhere. Although most patients are happy for you to take part in their care and observe learning opportunities, if you’re hovering at the bedside some patients may find it difficult to refuse even if they aren’t keen on having any observers.

If you ever notice any ‘Mrs Reed’ moments or see any aspect of a patient’s care that doesn’t sit right with you, it is so important that you find the courage to speak out and challenge these behaviours. For me, ‘The Nan Rule’ is a great mantra: if it’s not good enough for your grandma/parent/sibling/best friend etc.. then it’s not good enough for your patient. The #hellomynameis campaign started by Dr Kate Granger is another inspired idea to improve patient communication with empathy and compassion.

Never forget your patients are people too, always treat them with dignity and respect and speak up for them when you see situations you aren’t happy with. Always remember the NMC code of conduct and contact your AA and PEF if you’re worried about raising concerns.

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