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.


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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PEF’s Corner: Mat Stephenson, The Christie

Mathew Stephenson (1).jpgMat Stephenson is the second PEF in our interview series to help you get to know the PEFs for your placement areas and pass on a few pearls of wisdom! Mat works at The Christie Hospital in Withington, and won 2016 PEF of the year at the SNMSW Recognising Excellence in Practice awards! If you’re on placement here and have any issues or queries Mat will be more than happy to help.

What is your background in Nursing/Healthcare? 
I am an Operating Department Practitioner by background but like most PEF’s we are expected to have a working knowledge of nursing and all AHP programs to facilitate the learning opportunities within our workplace.

What do you enjoy most about your role as a PEF?
The role of PEF is very diverse but the biggest enjoyment is when I receive an evaluation or feedback that is filled with praise for the mentors and staff on the wards that have made an impact on the students’ learning and the student has enjoyed the placement and really learnt from the experience.

What is the most challenging part of being a PEF?
Not having enough time… it’s the little things that can take up so much time yet have the greatest impact on an individual. Besides the day to day routine work its always a challenge to do the work that is less interesting like admin and reports. Trying to keep all the students happy and give the best learning experience possible isn’t always possible for differing reasons but I try!

One piece of advice you would give yourself as a student…
Be curious and inquisitive, don’t be afraid to ask questions and ask more than one person the same question as you might get a slightly different answer or a different point of view then take the best bits and make yourself the best.

How can students get in touch with you?
My work email is Mathew.Stephenson@christie.nhs.uk and work number is 0161 918 7367. The Christie website is www.christie.nhs.uk and the School of Oncology has a twitter account for information about events; @TheChristieSoO. Don’t be afraid to contact to me about any query.

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PEF’s corner: Lisa Brown, MHSC


At a recent PEF forum we asked some of your friendly neighbourhood PEFs some short interview questions to help you get to know them better and pass on any wise words of wisdom! First in this series is Lisa Brown, PEF and OT at Manchester Mental Health and Social Care Trust, Thanks Lisa!


What is your background in Nursing? 
I don’t have one! I am an Occupational Therapist by professional background and have worked on acute mental health wards since I qualified in 2005. I currently work 2 days a week as a PEF and have done since April 2015 and 1 day a week as an OT.

What do you enjoy most about your role as a PEF?
I really enjoy getting the students feedback from placements and helping students get the most out of their placements. I’ve also enjoyed implementing inter-professional learning sessions in our trust so that students from different professions can learn to work together better in practice.

What is the most challenging part of being a PEF?
The most challenging aspect tends to be the administrative / organisational issues, ensuring we have enough good quality placements available and enough educators to accommodate the students.

What does Occupational Therapy mean to you?
Occupational therapy to me means helping people to help themselves. I enjoy finding out an individual’s story and tapping into their interests and values to enable them to live more independently and achieve their goals.

One piece of advice you would give yourself as a student…
Take full advantage of all your placement opportunities , ask lots of questions and ask if you can take the lead in things – I often waited to be asked and missed out to some extent by not taking the initiative.

How can students get in touch with you?
I am available by email via the form below. You can also follow our trust twitter account @PEFMMHSCT for updates or my personal account @OT_LisaB for general musings on mental health, occupational therapy and education.

Please use the form below to contact the author of this post with your comments and questions:

New Placement Resolutions

In late February I’m a bit slow off the mark for New Year’s Resolutions, but as us 3rd years start our Leadership & Management placement tomorrow I thought I’d write (in no particular order) about some ‘placement resolutions’ that I’d like to start doing  or things I already do that I need to keep up. For the more organised amongst you this is probably second nature but I feel like I would have appreciated these tips when I was in first year! I’m an Adult nurse but hopefully these things should be relevant to all fields so I hope you find this useful!

  1. Batch cook lunches for the week: I’m terrible for overeating when stressed or short of time and often find myself eating fas
    t food or ready made sandwiches on my break, leaving me feeling bloated and lethargic for the rest of my shift. This time around I’m going to make an effort to save money and stay healthy by pre-preparing food to bring with me to placement. It’s also a good idea to have some emergency cereal bars in your bag for a shift when you need an extra boost of energy!
  2. Pack your bag the night before: I’m really not a morning person, especially in winter when your alarm goes off at 5am in the dark and you feel like you don’t see daylight for weeks! Knowing that all my stuff is ready to go and all I have to do is fill a flabigger pocket gifsk and eat some toast like a zombie, makes it just that little bit easier to get out of bed. This sounds obvious but I try and put all my placement bits and bobs in a box all together- it’s brilliant to avoid rushing in the morning when the night before you’ve come home from a long day and thrown your name badge, ID card, fob watch, bus pass etc.. on the floor with your uniform!                                                                                                           Ps. Invest in a good travel mug! It’s the most useful thing I bought in 1st year!  Kim also has a great blog on preparing for placements (‘Pre-placement necessities’
  3. Always double check your PADIt’s actually embarrassing how many times I’ve had to go back to placement after finishing to collect a missing signature. Save yourself a trip and learn from my mistakes!
  4. Speak up sooner with problems: On a previous placement I had an issue, I raised this on the ward and also with the PEF, but unfortunately it wasn’t dealt with in the way I’d hoped and started to affect how I felt about going to that ward and was really getting me down. It took me a while to bring this up again with my AA, and realise that it wasn’t a satisfactory solution to the ward problems. Remember if you’re unhappy on placement and need to resolve an issue, don’t hesitate to ask! Usually PEFs are fantastic and your AA will always be supportive but if they don’t know about the problem, they can’t help you! If you need more information about where you can go to for Support on Placement check out the Placement Survival Pack.11535296_10153989835585820_926530824_o
  5. Take notes: I try and jot down things I’m not sure about to look up later, for example; a new acronym or a condition I’ve not heard of before. Then it reminds me to look it up later and jot it down in a pocket notebook. It’s also really handy to keep a list of useful numbers in.
  6. Background reading: If I’ve been allocated to a ward with a speciality I’m not familiar with I always try and read a bit more around the subject for example; common conditions, A&P/pathology behind it, main drugs I’m likely to see on this ward etc.. However if I’ve done this in some free time around allocation day it might be a long time before I actually start there so I’ve also started jotting these down in my notebook.
  7. Make a timetable: One of the hardest things about nursing degrees is balancing your time when you have so many extra things to do whilst you’re on placement. When you’re working you can just come home and that’s the end of your day, you don’t need to worry about working on that essay or writing some reflections when all you want to do is collapse in a heap on the sofa! I’ve tried to make myself a timetable as soon as I get my off duty, to try and organise my time around shifts so I don’t leave everything last minute- sticking to this however is another matter! I’d also say that if you feel your workload is too much, you’re not coping or there’s other things going on in your life that’s affecting how you feel- go and speak to your AA about it, don’t struggle on alone!

I hope you find some of these tips useful, got any of your own you’d like to share or suggestions for new posts? Please get in touch below!