DILP Week 3 – A&E lessons learnt

This last week has absolutely flown by!! I’ve kept myself very busy both in and out of placement which has been tiring but so rewarding!

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Scans following the admission of a lady with drowsiness and weakness following loss of consciousness

I can now run triage efficiently and effectively on my own and have been working with some really great nurses for the last two weeks who have taught me a bit of singhalese in between tasks. Key phrases you need to know as a tourist e.g. What’s your date of birth? What is your pain scoring between 0-10? Etc.

I’ve managed to get all the nurses to ask the patient for pain scores now which is a really vital thing. I only realised they weren’t asking properly when a woman who couldn’t speak with the pain in her abdomen or open her eyes fully had a 5/10 for pain written on her triage documents.. I’m in no way saying this is the only time I’ve come across falsified pain scores, unfortunately. It wasn’t at all rare to see Ward rounding forms where all patients conveniently had a pain score of 0 on my first placement in the UK. It wasn’t the case of course but writing this down meant less paperwork and less hassling the already over worked doctors. So it was sort of left unsaid and when I did rounding a and was accurate with pain scores it was met with a general groan from the staff because they had to chase up altering patients analgesia.

Pain is such a vital symptom to understand – this should be evident by the fact that all of our hospitals have a devoted “Pain Team” of specialist nurses that are like ache whisperers.

Changes in pain, not just the score but the type or the frequency can be the biggest clue you get about what’s going on with your patient and if their records aren’t accurately reflecting this evolution of their pain then we have failed that patient. For example, a headache.

It can be cause my 101 different things but if the patient is complaining of a sharp throbbing headache associated with noise or lights and also has a rash on their abdomen.. This could be meningitis. This patient might require urgent interventions. Equally, they might be having an allergic reaction or be dehydrated. However, without going into the details, we are pretty much running blind.

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This is not where anyone wants to be is it?? 

Literally 3 hours ago as I write this a woman who originally came in suffering from loose stools for 4 days arrested! She started coughing up frothy pink sputum then her heart failed, I was lucky enough to assist in giving chest compressions and ambu-bagging her to keep oxygen pumping around her system.

I had no idea what to expect from the other staff members in such a high-pressure situation but the respect and trust they showed me was pretty moving.

Having the doctors from CCU direct their questions at me about the patient, as a humble Nursing Student, was really empowering. I’m also very pleased to say that the patient’s vitals were stable when she left our care to recover in CCU.

Experiences like that today just remind me how privileged I am to be able to not only be a Nurse but to have this opportunity to travel half way across the world and still be respected, trusted and appreciated for all the hard work I have put into the degree so far. Nursing has always been a great passion of mine and it’s a truly wonderful thing when you can see that that passion exists in Nurses across the world who will work tirelessly next to you for the good of each patient that needs our care.

5 things I’ve learnt on my first placement 

That’s it – we survived our first placement! One step closer to that blue uniform. I’ve spent the last ten weeks on an elderly rehabilitation ward where the patients are quite poorly, needing help to wash, dress, eat and get to the toilet. I’ve had good days and bad, and it’s been physically and mentally challenging at times. Looking back, I thought I’d share some of the key things I’ve learnt so far:

1. Nursing is messy 256px-research-suggests-women-who-have-a-heart-attack-wait-longer-than-men--221603

…and the bodily fluids are only the half of it! It’s complicated and unpredictable and sometimes it feels impossible to use all the theory we’ve been taught at Uni in practice. There’s no ‘one-size-fits-all’ approach and I’ve had to constantly adjust and adapt to match the needs of each patient, who are all individuals with their own character, ideas and worries. No two days are ever the same, that’s for sure!

2. Healthcare assistants are our best friends

On my first day someone asked me to get a bedpan from the sluice. I literally had no idea what they meant or what I should be looking for – I think I walked round the ward for a good five minutes before I finally plucked up the courage to ask. I had to start from scratch and it was the healthcare assistants on our ward that really helped teach me the core elements of care. I especially loved seeing the way they relate to patients; singing a familiar song to a distressed patient with dementia or taking the time to paint someones nails. They have become invaluable allies and I owe a lot to their patience and encouragement.

3. It’s the little things that count

It’s so easy to get caught up in the long lists of jobs that need to be completed and forget what really matters to the patient. Whether it’s spending time combing someones hair or fetching a fresh jug of cold water, those small acts are what make people feel cared for.

4. Fake it ’til you make it

There have been few nerve-racking moments over the last few weeks; my first bed bath, giving an injection, doing a drug round – but patients can smell fear and I think when I’m anxious, they feel worried and uncomfortable too. Even when I’m nervous and my heart is going 100 miles an hour I now try my best to at least appear calm and in control. Hopefully one day it’ll all be second nature – but for now, I’m just going to have to fake it!

5. It’s down to me to make the most of every placement 

On a busy ward, you can’t spend every minute with your mentor or another nurse but as a result, you sometimes feel like you’re missing out on learning proper ‘nursey’ things. I’ve learnt to ask lots of questions and always have an ear out for anything going on – ‘what’s that? did someone say catheter?’ It can be tempting to watch procedures but one nurse told me not to hesitate and get stuck in – patients are usually understanding that things might take a little longer and can give just as much encouragement.

I hope everyone has enjoyed their first placement and we would love to hear about things you’ve learnt over the past ten weeks – feel free to post on our Facebook page.

High risk women and the importance of continuity of midwifery care

  So this week I’ve enjoyed working within the birth centre at my trust. The birth centre is midwifery led care for low risk women.  This unit only has midwives, there are no doctors, no CTG monitoring,  no medical equipment just relaxing rooms with lava lamps, pools, tea and coffee making facilities, a calm safe place to give birth. The women who are able to use these facilities ’ will have had the pleasure of MLC- midwifery led care throughout their pregnancy, enjoying the continuity of midwifery.  Whilst enjoying my first day me and my mentor got called to go to a heart and lungs ward to see a woman who was extremely anxious about her baby. At 36 weeks she was to have a C- Section at the advice of her  medical team and Consultant Obstetrician. The woman had cystic fibrosis and due to the long term use of steroids to treat her condition she had also developed gestational diabetes.  Once we got to the ward the nurses informed us of how anxious she was about birth, attachment and bonding, feeding, all the anxieties a low risk woman would have. They had been unable to calm her worries.  Throughout her entire pregnancy the woman had not seen one MW apart from the booking appointment at 12 weeks. This was because she was “high risk”. Being high risk she automatically qualified for Consultant led care .  All she had seen were her CF doctors and a Consultant Obstetrician. All the woman wanted and craved was midwifery care, she wanted to discuss her pregnancy, her pending motherhood, her feelings and thoughts of what was to come. Seeing a midwife made her pregnancy seem real putting her anxieties to rest. As midwives we are in a unique position, our role ultimately is to listen to the women we care for. Doctors obviously have to listen but from a medicalised point of view. Anatomy and physiology is always at the forefront of their mind.  It was rewarding to see how our chat had helped the woman, the relief on her face was plain to see, she opened up to us, spoke about her greatest fears, I found the whole experience so hugely rewarding. This is why I came into midwifery- to make a difference, to listen to women, to support them at their most vulnerable, to make them believe they can do it, they can birth, they can get through pregnancy, they are amazing! listening This experience got me thinking- High risk women need continuity of midwifery just as much as low risk women do, in fact in many ways potentially they are in greater need.  This woman had been medicalised her entire life and craved for the normality of pregnancy.  It is so important these women are not forgotten about. Yes absolutely high risk conditions must be monitored by obstetric means during pregnancy, intrapartum and post natal but midwifery offers a unique form of care that is just as important. why  

From fear to maternity……..

So, before I embarked on this student midwife jaunt I was a counsellor for 15 years (I did ALL sorts of counselling-general, bereavement, play therapy with children and adults, couples, mindfulness groups, Neuro Linguistic Programming, anxiety, depression, eating disorders, chronic pain management groups……no therapy stone was left unturned I was the CPD queen!) and when I started to think about retraining in a completely different profession I could not IMAGINE myself ever doing certain…..ahem….invasive procedures! I could not visualise myself (not matter how much I meditated!) as anything other than a counsellor; could not picture myself in a uniform doing medical type things!shocked face

Some may argue that rooting around in peoples subconscious’ for 15 years is pretty invasive but I was so confident and comfortable as a counsellor I was at that joyful stage of awareness/learning known as ‘unconscious competence’ so I didn’t even need to think when I was with clients anymore I  just was!

So, how did I get to thinking about how being a student midwife is not obscure anymore? How did my concerns about carrying out physically invasive procedures (not just vaginal examinations but palpating women’s abdomens, venepuncture, being physically present at such a life changing event etc) suddenly pop into my consciousness again? Because, as I was clipping my name badge on my uniform on Thursday night to go on a night shift just FOUR MONTHS after starting placement the thought went through my head of “off I go to work again….” in a kind of same old same old/blasé way! WHATTTTTTTT?! HOW did this happen?! Don’t get me wrong I wasn’t thinking about it in a boring way-I was excited and apprehensive but it was NORMAL! ME putting on a uniform and heading out to ‘work’ to do all kinds of things I could not even imagine myself doing in September has become…..

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This makes me wonder about how adaptable we are as human beings-is it a survival mechanism in us as social creatures that we have to create normality so we can fit in to our new surroundings? Do we/I crave normality and therefore make the abnormal/obscure fit into our frames of reference so we can feel comfortable again?

I can remember whispering to my fellow new student midwives over a pint or 2 on a ‘meet & greet’ night out before the course started “how do you feel about taking blood and doing VE’s?”; some were apprehensive like me but others were worried about other things that hadn’t crossed my mind like talking to women and holding a baby….it made me realise we all have our own hang ups but we push our boundaries, expand our comfort zone, feel the fear and do it anyway and all the other cliché’s I can think of to get us through challenging experiences! As my mentors have got to know me they’ve realised giving me a choice is not an option as I will always find an excuse to not do something I am uncomfortable with mainly for fear of hurting the woman! I tell new mentors “don’t give me a get-out clause just tell me to do it” which so far has worked well! It is likely self reflection will remain a huge part of my learning and at times, standing outside of myself and observing the student midwife stood clipping her badge on her uniform getting ready for another night shift allows me the space to remember how fortunate I am to be given the opportunity of another amazing career at this time in my life and to not take for granted any shift or any experience-whilst orange is the new black so venepuncture is the new CBT…..I may not love it but its a necessary procedure;-) Self awareness is a gift and I feel a necessity in professions such as midwifery as how can we be resilient if we aren’t self aware? I guess that is for another blog though!

My greatest struggle during placement in the community: ANTT

The one thing I found most difficult when working with the district nurses was understanding how to manage cleanliness and sterile fields when dressing wounds. You may very well hear a range of different view points about what is acceptable practice for Aseptic Non-Touch Technique (ANTT) in the community. On my first day, the nurses felt compelled to drill into me the idea that we were working in someone’s home and that ideal ANTT procedures are not always possible. I imagine most university students are as uncomfortable as I was having just come from clinical skills demonstrations that offer a perfect situation for ANTT.

Disposable_nitrile_gloveHowever, often the practice I saw was unnecessarily hurried and avoided maintaining proper ANTT because of time constraints rather than an established lack of opportunity. Some homes we visited were rather cluttered and very dirty and the lack of a reasonably clean surface to set the sterile field on was a challenge. Even so, there was often a tendency to forget to keep the sterile gloves sterile by not reaching in one’s pocket to get out a pair of scissors (when a fresh pair of sterile scissors should have been used). Some DNs would explain that even though they were using a sterile dressing pack, that the procedure was a ‘dirty’ procedure that did not require they maintain the sterility of the gloves. But practice and opinions differed so greatly from nurse to nurse and patient to patient that it became very difficult to get a sense of what was good practice and what was poor practice. By the end of my first week I had seen the same patient three times and observed three relatively different ways of approaching the ANTT needed for that patient’s wound dressing. Some DNs went to great lengths to explain their motives and others became angry when questioned about their choices during the ANTT procedure.

All I can recommend is that, if you start to feel uncomfortable about how ANTT is being used, read, read and read some more about ANTT. Get a very clear idea in your head about what it is for and why we do it. If you understand WHY we use ANTT, then chances are you’ll be able to evaluate the situation for yourself and come to your own conclusion about whether the patient was kept safe from infection during the procedure.

I feel that unfortunately, working on one’s own day in and day out can lead to poor practice creeping in. When no one’s watching, I worry that there is a tendency to let standards gradually slide and forget why you were using ANTT in the first place. Some DNs have thanked me and told me that they are glad to have students along because knowing a student is watching reminds them to make certain their practice is of a high standard and that student questions make them reflect on their own actions. Other DNs have told me that they think I am rudely questioning their practice that that I should remember my place as a student.  Be prepared to encounter both attitudes from practitioners, but never stop thinking about what is and is not good practice.

But when will I get to do ___ ?

Depending on the year you are currently in, you may be expected to do different things around the ward.

Don’t be surprised if, as a first year, initially you are asked to work with healthcare assistants to support the patients with washing and meal times.aqua-21491_640 Although you may be chomping at the bit to be doing ‘nursing’ tasks such as wound dressings and medication rounds, take a step back and remember that ensuring a patient maintains adequate nutrition/hydration and that they have their personal hygiene needs met are also part of the nurse’s job. Washing a patient is an excellent opportunity to check their pressure areas for any impending damage and act before a pressure ulcer develops. Helping a patient with their meals allows you time to assess how they are coping with eating and drinking – maybe their swallowing isn’t up to snuff and a referral to the Speech and Language Team (SALT) is in order. Remember that every moment you have with a patient is time to be answering their questions, finding out what kind of things they might be worried about, reducing their anxiety with information and support, and offering little snippets of health promotion in a casual and non-dictatorial fashion. Thinking beyond the patient, working with all the different staff members on the ward will help you get acquainted with the whole team. Understanding how a ward team function is very important to finding out how you are going to fit in during the following weeks.

From the minute that patient is admitted to your ward to the minute they leave, EVERYTHING is a nursing task and deserves your full attention. You will learn something from every task you do.


To put a bit of theory into your practice:

Assisting your patients with a wash is a wonderful time to develop the therapeutic nurse-patient relationship that can make a rather unpleasant hospital stay just about bearable. Muetzel’s (1988) model of therapeutic nursing breaks down our nurse-patient relationships into ‘partnership‘, ‘intimacy‘ and ‘reciprocity‘. The model is concerned with how we work together with our patients, how we create a professional bond and how we aren’t afraid to admit that we get something out of those nurse-patient encounters too.

It’s all in the model: showing patients we truly care about their wellbeing, exercising good communication skills, displaying compassion and making sure they know they can trust us to support them on their road to recovery. It includes valuing patients as equals who are capable of making their own choices about care given the right amount of information and support from their healthcare professionals. It also says that it’s ok to give as well as receive. Nursing is a tough profession and most of us, when asked why we nurse, will give a reason that essentially expresses a desire to care for others. Part of caring for others is how that makes us feel in return and being aware of what we get out of nursing is important – the pride in the profession, the satisfaction of solving a problem, the joy we get from helping those in need – all these things keep us going through the long days and nights at work.

Muetzel PA (1988). Therapeutic nursing. In Pearson, A. (Ed.), Primary Nursing: Nursing in the Burford and Oxford Nursing Development Units. Croom Helm: Beckenham.

Children saying “no” to you.

Something that has now become more apparent to me whilst working on a ward is, children do not help you to help them when they’re ill. You must be prepared for them to frequently say “no” to you whilst you’re trying to make them better.

“Hello there *patient’s name*, my name is Kim, can I put this lovely sticker on your finger please, it will tell me how quickly your heart is beating?”

“No”

“Can I now place this under your arm to take your temperature?”

“No”

“Can I just put some of this magic cream on your hand?”

“No”

“Can you swallow this medicine for me, it will make you feel a lot better?!”

“No”

Be warned.

Anything that will make them feel better is something they will probably refuse. Kind of like some children with their fruit and veg. You will learn in University all about capacity, consent and how patients have a right to decline treatment. But being a children’s nurse has slightly different exceptions which I still struggle to know the boundaries for. If this child is saying no to me taking her temperature can I still do it? The answer is yes. Don’t worry! In these types of situations the parents normally start laughing and hold the child for you so you can do what you need to. The parents know that you’re not doing anything unnecessarily and they want their child to be better, so don’t worry! If you ever feel uncomfortable doing something again, don’t worry! You can always tell the child and parents that you will go and get a more qualified nurse and ask a staff nurse to help you.

Just be prepared for the word “no”.