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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‘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.

Image result for bristol stool chart

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.

 

Tools of the Trade – Mental Health Nursing

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Assessment or screening tools are key to gathering a whole wealth of information from a client and they can often lead to them opening up about other or underlying issues that may be impacting on their health. How and what they answer can give you insight into their current feelings about things as well as provide a baseline of presentation to record any future changes and used to point towards treatment required. Being able to monitor someone’s recovery progress can help staff encourage and motivate a person, just as being able to monitor someone’s deterioration can help staff adapt treatment and interventions appropriately.

Tools are not always perfect and we have to work with them openly and carefully using them as a guideline to help support the treatment or diagnosis we provide. Below is a short list of the some of the assessment tools you might come across on placement;

The Hospital Anxiety and Depression Scale (HADS) – Used for Anxiety & Depression can be used in community as well as hospital. It is a 14 question Psychological screening tool assessing the severity of symptoms.

Generalised Anxiety Disorder Questionnaire (GAD-7) – Screening tool used to measure the severity of Generalised Anxiety Disorder. 7 questions that can be administrated by a health care professional or self-administrated by the client themselves.

The Mini Mental State Examination (MMSE) – Commonly used short assessment used for screening for any dementia or cognitive impairment concerns are suspected. It measures cognitive functioning, and can be used to monitor change. 11 item tool taking around 10 minutes to administer making it a quick and useful tool to use.

The Addenbrooke’s Cognitive Examination (ACE) –  Well validated assessment tool for clinic setting assessment of cognitive functioning. This measures cognitive domains including language, visuospatial, memory and attention.  Usage is usually in part with other screening tests such as blood test, ECG and MRI scan to inform a diagnosis.

The Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS) – Is a self-assessment tool for measuring the side-effects of antipsychotic medications. Red herrings are included to check the accuracy of the results. The 51 questions are based on true side effects with 10 being false  ones aim to help patients Identify, understand and gain awareness of side effects they could be experiencing.

The Alcohol Use Disorders Identification Test (AUDIT) – A basic screening tool used to pick up the early signs of hazardous and harmful drinking and identify mild dependence and highlight if a need for assisted withdrawal is required.

There are many varied tools assessing risk used by health care professionals in all fields and in  a wide variety of settings. It is important practitioners should take care to always explain what is involved,  how long it will last and how they can help a patient and their treatment.

Using an assessment tool can help uncover more information about a patients situation and help to encourage conversation that could provide valuable information to inform their care is more personalised and help reduce risk.

Keep your assessment tool box handy and help patients access all areas in health care support.smile

Week 2 – DILP Questions Answered!

At the end of my second week working in a Sri Lankan hospital I am pretty exhausted. It’s been a really full on week; my first ever in A&E and it’s been absolutely invaluable. I’ve observed lots of amazing Nursing and care but can’t seem to keep myself from thinking “Oh, that’s not how we do it in England” every time something surprises me.

IMG_7797.JPGAfter last week’s post a few of you had some questions about the DILP and how myself and others went about it. Since I have organized my placement independently I referred to my friends currently working in Andhupura who have gone through Work the World for their DILP about their experiences too. They explaned that they chose Andhupura because it seemed to have a richer culture compared to Kandy and was near the beaches of Trincomalee which is one of Sri Lanka’s best preserved pieces of coast-line with clear blue waters and lots of snorkeling opportunities.

Firstly and often most crucially going abroad for this placement is an expensive undertaking. Going through an agency condenses all the costs however into one lump sum you pay directly to them to organize accommodation, flights etc. this can be paid in installments or in one go but the deadline is a couple of months before you fly. It has been known for people to fundraise to pay for their DILP but none of the lovely Ladies in Andhupura did but we were told by the DILP unit lead to expect to pay around £3000 through an Agency so fund raising may be a very good option.

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Our ECG machine – complete with metal suction cups

Since I organized mine independently it cost a lot less, around £1500 for flights, accommodation, visa’s, insurance and the cost of living whilst I’m here. Although recommending someone to go it alone abroad is much like recommending someone to do a home birth without alerting a midwife. It can be super rewarding and great but if something goes wrong – it can be really disastrous.

Work the World have been really wonderful with all the students who worked with them, really helpful and easy to contact which made the whole process very straightforward and stress-free. Also the students (who come from all over and include OTs and Medics) with Work the World all stay near to eachother which is nice to have a little support hub of people all going through the same thing.

People were curious about time off and whether or not we have the ability to actually experience the country and the culture whilst working 37.5 hours a week. We were unanimous in our answer of YES!! 7.5 hours a day with early starts does mean it’s not advisable to be staying up late every night having cocktails at a beach bar but there is always the weekends for that!

I’ve been working 8 hour shifts (excl. breaks) 7-3.30 each day which leaves me a big chunk of the afternoon to do as I please. With a coupe of 12 hour night shifts thrown in I’m finishing placement in 6 weeks (30 days) as opposed to the 7 weeks (33 working days excl. bank holidays) allocated by the university. This means I’ll have a week at the end of my placement exclusively for free time.

I’m lucky enough to be able to stay on for a while after placement is done to travel around the island a bit and holiday with my family and boyfriend which is a really nice goal to aim for when I’m missing home.

IMG_7810

“Difficulty walking, slurring speech, brain stem stroke”

The language barrier can be frustrating at times but all medical terms are spoken and written in English so you can spot quite easily what each case is about. Most of the Nurses I’ve encountered have a good grasp of English so if you ask questions, they will try their hardest to explain. The best thing about working abroad is the independence. You are relying on your Nursing instincts and knowledge, I’ve learnt a lot from my mentors and patients but I have taught them a lot as well. I’ve introduced a new standardized handover tool, which has been saving hours of staff time. I’ve been screenshot-ing and explaining tools such as the Bristol Stool Chart and the SBAR in an effort in increase the use of evidence based assessment tools. The staff are really keen to learn as am I which makes for a really engaging and exciting atmosphere in the ward.

Again any more questions you have about working abroad, working independently or the DILP in general please do comment on our Facebook page or email us at enhancingplacement@gmail.com