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.

 

 

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

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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?

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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.

My ‘lollipop moment’

Have you ever had your life changed, even just a little bit, by a total stranger?

Several months ago, my boyfriend showed me a TED Talk called Everyday Leadership. The premise of this talk is about ‘lollipop moments’, when a stranger makes a difference to your life. The speaker, Drew Dudley, was lucky enough to be told by the person he helped, and how much of a difference he made to her life. The really interesting point that Drew also makes is how we often don’t realize that we make these differences to people!

I had my ‘lollipop moment’ today, at the Freshers fair whilst I was working at a stall. A woman approached the stall with her friend, and recognized me immediately. She told me that I had talked to her before her nursing interview this year, and helped her feel a little bit less nervous. I didn’t remember this moment until she reminded me!

I think the concept of ‘lollipop moments’ applies to nursing really well. Although it may sometimes feel as though we are endlessly doing paperwork and working in areas horrendously understaffed, we are making a difference. Somewhere in the world, you have changed somebody’s life for the better, just by doing what you love!

Have you ever had a lollipop moment, or did someone change your life for the better? Let us know by commenting, tweeting us or write your own blog post and submit it to enhancingplacement@gmail.com

Student Nurse NOT HCA

A really common occurrence, particularly for students in their first year in practice, is the feeling or impression that you are taking up the role of a Healthcare Assistant (HCA or Nursing Assistant or Auxiliary as they used to be called).

If this is you do not panic!!

study--undergraduate.jpgAn important point I feel it is essential to make is that a lot of the tasks that fall to HCAs in modern units are vitally important to that person’s Nursing care and are highly educational, need-to-know jobs. For example, washing patients or doing observations. The opportunity to wash patients gives you an invaluable period of protected time with that patient to really form a strong therapeutic relationship and hear what it is that is truly affecting or worrying them that day – use this time well! Also you get to see your patient’s skin from head to toe and make observations about their condition or their ability. You get to share some amazing moments with patients for example if they haven’t been able to walk to the shower for some time, being able to facilitate this really empowering event is really very moving. Some patients may have thought they would never be able to get back to that fitness!

Equally when there is a crisis and the senior nurses come to the fore – the first intervention more often than not – is a full set of observations. Being so used to doing them you can put a BP cuff round a patients arm in your sleep means you can do it quickly in a crisis and that builds your confidence when those events happen.

All that said and done – never forget the vital part of what makes Student Nurses different to HCAs. We are here to learn. You are Supernumerary. You may want to help out with the routine tasks of the ward’s running, and that is a really wonderful trait to have and please never lose that – but don’t feel obligated.

I think all Student Nurses develop their own little ways of making sure they get treated as they should be and have access to all the best educational opportunities our wonderful placements afford. As always, with any issue in practice, your first port of call should be your mentor. Some of the best mentors I have ever worked with had a really simple but effective way of making sure I got the best out of my day by taking 2/3 minutes in the morning after handover to set goals for each day.

I know it sounds straightforward, but if you say “I would really like to complete the medication round with you today” and your mentor hears and acknowledges it, the likelihood is, it will happen! If daily chats isn’t possible, aim for a weekly goal, “I was hoping that this week I could do a wound dressing/remove a catheter/remove a cannula/ observe the ward round”. Communication is absolutely key to achieving what you want out of each placement and making sure your mentor is aware of your goals and can properly support you to achieve them.

PEF and all-round Superstar Tracy Claydon uses the alias of “Beryl the Toxic Auxiliary” to discuss the tricky situation that can arise in practice of HCAs who will sometimes excessively delegate tasks to student nurses (often with a scowl on their face). The best way to handle this issue is to proactively set your own tasks – before Beryl can delegate all the obs or turns to you! Maybe try having more of a discussion when jobs are being delegated, such as “OK if I do these obs, can you check turns before I do the meds round with my mentor?” or try taking your own patient(s), obviously under the supervision of your mentor but having the responsibility of that patient you will be busy providing all their care, doing all their documentation etc.

Handling complaints: what I never learnt as a waitress

I have never been good at receiving complaints. Before I started my nursing degree, I worked as a waitress for 5 years. It was not uncommon to deal with customer complaints on a daily basis, and I would always just say “I’m really sorry about that. I’ll speak to my manager” which was always a fail safe. 98% of the time, the customer didn’t want to speak to me anyway!

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Accurate picture of me listening to customer complaints

But that changed when I started my nursing. Suddenly, whilst trying to make small talk with patients, I was being confronted with complaints about care they had received in the past or at that very moment. I couldn’t get away with my usual spiel because care complaints are more specific, more personal. You have to say something, and sorry doesn’t quite cut it.

I remember, very vividly, the first time I saw a nurse deal with a complaint efficiently. The patient in question was raising her concerns about the referral system for district nurse visits after a stay in hospital. Her care had been delayed due to this. The nurse I was working with listened to her very carefully, occasionally (when appropriate) asked for more detail and did not seem flustered at all. She then thanked the patient, said she would follow this up but urged her to voice her complaint at PALS.

PALS stands for Patient Advice and Liaison Service. It is confidential, and designed to provide support for patients, relatives and carers.

I was amazed at how calmly the whole situation went. Although the patient was upset initially, she was clearly at ease by the end of the visit, and I felt it was due to her being able to voice her opinion. And she was actively encouraged to talk about her concerns as Image result for complaintsit helps the NHS grow as an organisation! And it inspired me!

Since this event, I feel as though I have been inundated with patient complaints. Sometimes I feel as if there is a secret sign on my head that says please voice your thoughts at me!. I have now had endless practice at being calm and friendly, with some situations leading to me having to be a little firm (I will not be shouted at). I find that listening a lot, speaking barely at all, seems to work. Asking them to expand, answering questions when needed, and most importantly not denying their claims. It is extremely important, I think, to acknowledge that not every care interaction is perfect or goes to plan. We must embrace feedback, negative or not! Whether it comes from a staff member, a patient or a relative; complaints should be listened to!

Always speak to your mentor or a staff member about a patient’s complaints. 

Community Matrons; the role we need

I bet you’re thinking, what is a community matron? It sounds very official and a bit scary…but you couldn’t be more wrong!

Within the community healthcare team, there are a wide range of roles. I am currently based with the district nurses (can you tell I love community yet) and I wanted to see how it all fits together. I had never heard of the community matron role, until I met my placement’s local one. She gave me a really fabulous explanation of her job, and I spent two days with her!

Community Matron’s are the Advanced Nurse Practitioners in community. They work alongside the GP’s, District Nurses, Social Workers, Occupational Therapists, Physios etc. to ensure that more vulnerable patients living in the community do not end up in hospital needlessly. Using their amazing medical/psychological/social care assessment skills, they are able to provide support for patients with chronic conditions such as *COPD or heart failure. This is an absolutely fantastic, and much needed role, within the community. They provide extra support to all the healthcare professionals in community.

Whilst working with the community matron, I got a really good idea of what there job is. It’s a very diverse job! One patient we met, the wife was concerned about her husband’s medication. As the main carer, she felt as if not all the medication was necessary and did not understand the need for them. We were able to sit down and have a long discussion about the home environment, how they are coping, and of course review the medication. At the end of our visit, the patient’s wife thanked us profusely for helping her understand. She was much calmer, and felt as if her questions had been answered. One hour made a huge difference to herself and her husband!

Another example was an elderly lady who had *COPD and recently had a chest infection. The community matron ensures that this lady, as well as many other patients with long-term conditions, always have antibiotics in the house, and teaches them to recognize signs of a chest infection. This means the infection is dealt with quickly, it encourages self-care, and reduces the potential stress on GP and A&E services! During our visit, the matron taught me how to listen to chest sounds and undertook basic observations. This is to keep an eye on the chronic conditions her patients suffer from.

This is only a small insight into the work of community matrons, and I could easily sing their praises all day! Personally, this is what integrated care should look like.

I would wholly encourage anyone, no matter what stage in your training, to get a spoke with a community matron.

 

 

 

*Chronic Obstructive Pulmonary Disorder

The joy of community nursing

Community is often painted as marmite- you either love it or you hate it. But is that strictly true? Surely there is something about every placement that can be enjoyable, and not so enjoyable!  I will first admit that my heart lies in community. I knew within the first few days of my placement in first year that I wanted to work in the community. So I thought I’d make a little list about why it’s just so amazing. 

You have to expect the unexpected! You aren’t in the relatively controlled environment of the hospital, you’re in a patient’s home/room. Anything can happen, even trying to stop the pet dog from jumping on the bed during catheterisation!

It really is community based nursing. No matter what area you work in, you’ll know the people, their attitudes and the roads like the back of your hand. It’s really refreshing to be moving around constantly instead of endlessly walking around a ward or clinic.

Improvisation is key! Can’t find the correct wound dressing? Come across a new skin tear? Can’t access the patient’s house? Better make it up! I’ve seen some amazingly ingenious solutions which I’ve then stored in case I ever come across it again. It’s one of the best ways of learning!

Community nurses can be a lifeline. Many patients you will visit in the community are elderly, some of which are very isolated from society due to mobility issues, lack of family or the fact that they live in rural locations. Often, community nurses are the only people they interact with in the day, and they appreciate their presence immensely!

The patient-nurse relationship is very different! As soon as you enter someone’s home, you are entering their territory and you follow their rules. I feel that this allows patients to have a larger role in care decision-making. It is what holistic nursing is all about.

Community nursing is not for everyone, but never underestimate it’s ability to build up your skills!

If you’ve had a community placement, and you’re feeling creative, why not write us a blog post? Simply send us an email at enhancingplacement@gmail.com. We always welcome new content!