Nursing behind bars: Q&A with student nurse, Laura, who shares her prison placement experience

One of the incredible things about nursing is that it is one of the few professions that reaches people in every part of society. This includes prisons which could arguably be considered one of the most challenging environments in which to nurse. Earlier this year student nurse Laura Golightly (pictured) was among a handful of student nurses to be placed at a prison in Manchester. We are delighted to share this Q&A with Laura who describes her experience working alongside the prison nursing team, including the daily challenges but also the huge variety of nursing skills and confidence she gained from this rewarding placement.Laura pic

What originally drew you to applying for a placement in a prison?

I have always had a fascination with prisons since growing up and watching compelling documentaries made by influential documentary makers like Louis Theroux. For many people, and certainly for me, this sub-section of society living their life behind bars in massive secure institutions was really intriguing and something that I felt I could have no real concept of. The reality of life within prison is often something that’s kept very private from the general public, including the mental and physical health problems faced by inmates and the concept of institutionalisation, this threw up some really interesting and thought provoking societal questions about the effectiveness of the prison system as a whole which I really wanted to explore, not only as a health professional, but on a human level also. It had really been a desire of mine to work within a prison, safe guarding very vulnerable members of society, before the opportunity even arose so when I saw the email detailing the placement, I knew I would do everything in my power to secure it.

How did you feel when you arrived for your first day?

I was completely overwhelmed when I first stepped foot into the prison for my first day. Starting a new student placement can be intimidating at the best of times, I’m often left feeling anxious about meeting the staff, performing up to standard, not knowing enough and many of those little worries that seem to occupy your head before starting a new placement. There is certainly plenty to consider turning up on your first day so then to be turning up to a huge Victorian building which seems to dwarf even such vast city centre buildings surrounding it, complete with barbed wire running around the parameter and prison staff greeting you with a sharp eye and a pat-down, well it certainly puts things into perspective. The first day my mentor took me into the grounds and gave me the grand tour, we discussed what general day to day life is working within the prison and he soon made me feel at ease. I have to say though, it did come as a bit of a surprise when we discussed this over a coffee and he pointed out to me that the staff serving us in the café were actually inmates.

What was your daily routine like on placement? Describe an average day.

There was no real average day within the prison, this was one factors I particularly enjoyed about the placement! There are three main areas to work and these are on reception, on the health care unit and on inpatients. The role is vastly different on all three which was fantastic for bringing variety to the role as nurses were rotated throughout the week. On reception we would take care of the medications for all inmates leaving for court or being transferred out and we would medically ‘fit’ them for departure, we would then also take care of all inmates being transferred in, this was the really interesting part. We would conduct an assessment with the patient discussing their past medical history, recording observations, their general contact details, the reason they have come to prison, their mental health, health promotion advice and some screening tools, this was their first point of contact with the medical team so there is usually a fair amount to cover and they would have a follow up within the first 72 hours to once again check in on them and discuss anything they may need to add since their first assessment. A day on the health care unit would consist of giving the meds for a specified wing (which could often take hours with the cocktail of meds some inmates are on) and then reporting back to the health care unit to complete the clinics for the day. There was an afternoon clinic and a morning clinic within this prison and these would often be clinically very similar to a GP surgery clinic. There would be many different health professionals running specialist clinics also such as psychiatric, counselling, smoking cessation, sexual health, BBV, dentistry, optometry and more, just as you’d expect to see in the community. The inpatient unit was quite different all together as these were the extremely vulnerable patients, it mainly consisted of mental health nurses and prison officers who were specialised to deal with the kind of inmate that presented in the unit. It was nothing like what I could have imagined, with huge solid metal doors, no windows, rooms without anything at all inside, no real equipment and it seemed to be constantly deafening with lots of screams and shouts from inmates. On top of all this there was the emergency response radio one nurse would have responsibility for, this would be used to request emergency medical first response. While I was on placement I attended these calls for a range of incidents such as fights, overdoses, inmates high on illicit drugs, cardiac and respiratory disturbances and mental health crises.

What kind of clinical skills were you able to practice with the prison nursing team?

The clinics were fantastic for practicing clinical skills, with lots of hands on experience being available. ECGs, dressings, injections, wound closure, suture removal and observations were all common practice. Every morning and afternoon there was the opportunity to complete the medications round also and due to the vast opportunity for spokes within the prison I also managed to complete a mental health assessment, smoking cessation assessment and observe the work of the specialist drug and alcohol team.

What do you think are the most challenging aspects of prison nursing?

The most challenging aspect of nursing within the prison for me was the prison regime itself. Many individuals within the prison have very low wellbeing for obvious reasons. To prison staff they are inmates, however to medical staff they are patients, this creates a very tricky dynamic when it comes to dealing with their needs. Being unable to encourage patients with activities to promote wellbeing was very difficult, I struggled to encourage patients to be active when they are only entitled to one hour in the yard a day and they are kept locked up in their cell for such prolonged periods of time. I struggled to encourage patients to connect with loved ones when they are only allowed a certain amount of visitation and many of the relationships the prisoners keep are strained due to their absence from home. I struggled to encourage learning when often classes are full up with long waiting lists and staffing levels inappropriate for the level security needed. The problem with prisons is that they aren’t therapeutic environments and this creates a vicious cycle that many vulnerable people fall victim to.

What did you enjoy most about your placement in a prison?

I can honestly say I enjoyed everything about the placement. The staff were all fantastic, great fun, welcoming and always happy to teach, my student colleague on placement with me was lovely, the prisoners were generally very polite and interesting to talk to. Being exposed to all the different healthcare sectors and how they are applicable to the prison community, highlighting the different demands of this small sub-section of the outside population was fascinating and I learnt how to deal with a patient who’s needs were often vastly different than what I was exposed to in my general training so it was fantastic to gain this different and unique experience.

What I really want to get across to nurses that would potentially consider a career within the prison service is that it really is a fantastic and unique experience. Often patients have very complex needs and this can lead to a really exciting and challenging working environment which really allows you to make a difference for your patients. Many of my friends and family thought I was stupid for wanting a placement they perceived as so ‘dangerous’, I really want to communicate how safe I felt in there. The prison officers are very well trained and experienced and look after the safety of the medical staff absolutely superbly. Do not be discouraged by fears of safety as officers are always on hand to assist you and will never leave you alone with a prisoner. Security measures in there are top priority for prison management and you’d never be left to work in an unsafe environment. If you have a keen interest in working with challenging individuals and nursing in a holistic and non-judgmental manner with a particular interest in mental health then the prison environment could be just right for you.

Thank you, Laura! It is fascinating and valuable to hear from other student nurses and midwives working in all kinds of different placement areas. If you have an placement experience or reflection that you would like to share on our blog, please do get in touch! Find us on Facebook @UoMPlacementProject or email studentnurseplacementproject@gmail.com.

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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.

“The doctor says I’m dying”: tough conversations about death

One of my most vivid placement memories was my first conversation with a patient about dying. One afternoon I went to check on Joan (name changed), a lady in a side room on an elderly ward. I was helping her to have a drink when she looked up and said: “the doctor says I’m dying.”

I froze. My stomach turned and my mind started racing, taken aback by a statement I felt totally unprepared to respond to. I had grown fond of Joan and to see her so distressed was upsetting. I felt a sense of panic, worried that I might say the wrong thing.

I knew from the handover that morning that Joan was receiving end of life care and from what the other nurses had said, she was deteriorating and it was unlikely that she would get any better.

Taking a deep breath, I thought back to our communication lectures which covered how to deal with difficult questions. I drew up a chair next to Joan and holding her hand, I asked some straightforward questions like ‘when did you discover that?’ and ‘how does that make you feel?’, trying my best to mask my own anxiety and appear relaxed.

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While I think I started off ok, all of a sudden I panicked; I didn’t know what to say next.  Almost without thinking, I said: “Don’t worry Joan, we’re all doing everything we can to get you better and back to your normal self.”

I immediately felt awful and her face said it all; she knew I was covering. I said it out of a desire to help Joan stay hopeful, optimistic, but in reality it sounded trite, like I was brushing her off and trying to avoid a deeper conversation. I think that it made her feel worse.

Kicking myself, I spoke to my mentor who reassured me that she too struggled with questions like those and some research when I got home that night revealed that I wasn’t alone – apparently it’s common for healthcare professionals to avoid or block difficult questions, particularly about death or dying. I suppose we like to focus on how we can ‘fix’ things and don’t want our patients to lose hope.

Looking back, I wish I’d spent more time with Joan, even just to sit quietly by her side. She may have had more questions that she wanted to ask and as a student nurse, I may not have known the answers but I could have found out on her behalf.

Honesty and courage are such important parts of nursing, especially at the end of someone’s life. Sometimes the best thing we can do is to be there; to listen, answer questions and ease fears – or just to hold someone’s hand and let them know that they are not alone.

Student Nurse Advocate

images.jpegAdvocating for patients, in my opinion, is one of our most privileged roles and one we should take very seriously. I have often found, our position as Student Nurses affords us a certain advantage when it comes to patient’s openness right from day 1. Because we are often very hands-on, we know our patients very intimately and they feel more able to open-up to us about smaller concerns they may not feel were important enough to raise with their doctor or consultant for example. This carries a responsibility for us to make sure we take all patient’s concerns seriously and act on/escalate anything that, using our theoretical knowledge, may be of importance to their care. This also takes a pinch of courage to have confidence in your instincts and “back yourself” as we say on the Rugby pitch.

Last week while assisting a patient with his wash (which is often a time when I learn the most about a patient) he told me he hadn’t slept well that evening as he had visited the bathroom over 10 times in the night. This patient was due for discharge in the coming days so this was concerning for me. As an elderly gentleman with hypertension, heart disease and other comorbidities, he was at risk of Falls and if he is going up and down to the bathroom so regularly, especially in the night, he may sustain a serious injury such as a fractured neck of femur. I looked through his drug kardex and found he was on very high doses of furosemide, a loop diuretic that is often prescribed to patients with Heart failure to prevent oedema.Renal_Diuretics.gif

I asked the patient if he was happy for me to discuss this with his doctors and a specialist continence nurse to see if something could be done to help either reduce this frequency or make provisions for his discharge so he isn’t at an increased falls risk, he agreed and I approached his doctor.

This encounter wasn’t entirely successful. When I proposed reducing his diuretics to the doctor, initially his response was “Do you want him to die of heart failure?” – in front of the patient…

keep-calm-and-back-yourself-4Not exactly the response I was hoping for, but I explained my concerns from a Nursing point of view and emphasised I am aware that his furosemide was prescribed for a reason and it is entirely his decision, I just wanted to advocate my patient’s best interests.

This exchange I felt didn’t end on a particularly positive note, so later in the day I apologised to the doctor saying “I didn’t mean to question his treatment I just wouldn’t feel comfortable if I didn’t make you aware of his concerns to see if we could work together towards a solution”. The doctor was much more amicable and smiled and said he understood and would consider what could be done.

Not long after this, the same doctor stopped me and said he had written a letter to the patient’s GP to recommend reducing his diuretics in the community and observe his response. He felt changing his medications the day before discharge might impact on his fitness for discharge. He also suggested trialling Oxybutynin. When I recognised Oxybutynin as an anti-muscarinic (which would improve his feelings of urgency), his face lit up. I have a feeling, he may not have expected me to possess such knowledge.

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So many speech bubbles but 1 shared goal – patient’s wellbeing

Only upon writing this have I realised just how many units of study went into this encounter; Communications, Anatomy and Physiology, Pharmacology, Applied Pharmacology, Nursing Therapeutics, Recovery focused care and Medicines Management all informed my actions in this case. Reflecting on this scenario I am really pleased with the outcomes we achieved. Not only was the gentleman’s GP made aware of our concerns and recommendations but I managed to speak to the Trust’s continence specialist nurse and get her recommendations for interim provisions to help the patient transition into community. I fed all this back to the patient who was visibly relieved and so grateful we had pursued his concerns and formulated an action plan he understood and would work for him.

Advocating for patients is a vital part of the Nursing role and we can see advocacy in the NMC code in various different guises (see 3.4, 4.1, 8.6, 8.7 & 9.3).

Raising Concerns

Whilst in practice, unfortunately, sometimes we can witness bad practice. It’s not a situation I would wish upon any student nurse or registered nurse for that matter as it immediately puts you in a very difficult position.

Yes, in the perfect world, there would be no internal conflict, you would identify the issue, escalate it to your manager or mentor and trust that it will be dealt with appropriately and with discretion and professionalism. However I know in my circumstance, I was/am struggling to trust that sharing my concerns will not impact upon my learning and education within this ward. This isn’t based upon anything other than my own fear of self-preservation, which makes it harder.whistleblowing

You’re faced with a decision, to voice your concerns and risk an uncomfortable and strained time in practice or say nothing and risk patient safety/dignity/pride. It really isn’t a toss up in my opinion.

The process is intended to be as pain-free as possible. Speak to the relevant individual, be it PEF, Ward Manager, Academic Advisor or Mentor and your concern should be dealt with in a professional and serious manner befitting the circumstance.

I have to say that as soon as I raised my concerns I felt an immediate sense of relief and confidence. Confidence that I had done the right thing for my patient, patient’s to come. I had 3 weeks remaining in my practice area and this was rather terrifying as I thought I would be identified somehow and treated poorly for raising concerns in practice, this I am very happy to report WAS NOT THE CASE. I wasn’t treated any differently whatsoever, I felt supported, trusted and above all I felt like the University was proud of me speaking up when I did.

This feeling was reinforced on Monday when placement allocations came out. A very close friend of mine has been allocated the same placement in which I experienced poor practice. I could have easily ignored the issues in the ward. Easily put them to the back of my mind and they would have continued and other Students would have struggled and felt as conflicted as me but because I spoke out – those issues have been resolved.handshake

I was able to say to my friend in confidence that any obstacles I encountered in practice have been resolved. No placement is perfect but if each student that encounters issues keeps quiet – they will never be perfect.

It can be very easy for student nurses to lay the blame for poor practice areas at their mentor’s feet but we have our part to play as well. Be honest in your placement evaluation and be honest with your mentor throughout your training – if they know what works well and what doesn’t that can only lead to improvements in how they teach and how you learn. So BE BOLD and SPEAK UP, who knows the number of people that will benefit from your honesty in the future.

PEF contact details can be found via this link:

http://sites.bmh.manchester.ac.uk/nursing-mentors/contacts

How to beat second year blues

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With second year around the corner, I’d be lying if I said I wasn’t a little apprehensive.

I’ve heard of the elusive ‘second year blues’ and worry that they might already be setting in. Despite having a year under our belt, the end goal somehow seems further away than at the beginning. We’re a year wiser, with a better idea of the challenges ahead…and let’s face it, we’re probably all a year poorer too. All things considered, its no wonder we might feel a bit down.

In the blissful ignorance of first year, I ignored second and third years warning us that we’d feel like this – turns out they were right! In a quest to ease my own anxieties, I’ve asked the for their tips for beating second year blues. Here’s what they said…

Get ahead

I know most of us have spend the last few weeks catching up on sleep, earning some pennies or reminding our friends that we still exist, but it’s worth having a look at what’s coming up. By second year, we’re expected to be independent learners, so its up to us to be proactive and find out what is in store for us over the next year. I’ve been putting it off, but it’s time to get organised, dig out the diary and log in to Blackboard…what’s my password again?

Set goals

Somehow I’ve managed to erase all memory of PAD submission day, which seems like ages ago now, but I remember that we were asked to set some goals for the year ahead. I’ve just had a look back at mine and they actually make some sense. Personal development plans can sometimes seem like a bit of a box-ticking exercise, but having a goal in mind for second year will give you something to focus on and makes the time fly by.

Avoid stress

When I started this course, I made a pact with myself not to leave everything to the last minute. In my last degree, I tactically worked out my words/per hour ratio (about 400), convincing myself that it was totally fine to leave a 3,000 word essay to 24 hours before the deadline. Yeah, I always got them in, but I was an absolute wreck. Believe me, its not worth the stress. This degree is full on enough as it is, so help yourself out by starting early.

Oh and this applies to overcommitting too – a lesson I’ve learnt the hard way. Figure out what is really important and realise that it’s ok to say ‘no’ sometimes. I still haven’t mastered it, but it’s a work in progress.

Talk it out

Chances are that most of us will feel down at some point over the year, but if ‘the blues’ hit, don’t bottle it up.  With hundreds of student nurses about, you’re bound to find a kind, listening ear and you might find that others are feeling the same way.

Also, don’t forget the PEFs are there to address any issues you might be having on placement – take a look at this blog to find out more about their role and how they can help.

Remember it’s not all about nursing

Maybe it’s just me, but does nursing have a way of taking over your life? While on placement, it feels like you think, breathe, dream nursing – sometimes you just need to switch off. Step away from the stethoscope and plan some totally non-nurse activities for the weekend. A break will do wonders.

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Keep calm and carry on nursing

Conquering second year and banishing those blues is about finding the right balance. This course can take over if we let it, but by staying organised and making time for the other things we love, we can actually be better nurses in the long run.

See you next week!

Out on Placement

Guest Blog written by Emma Wilkes


I think it’s fair to say that most student nurses are nervous before starting a new placement, however LGBT students may feel extra nervous. Whether it’s awkward conversations about your love life, or a worry about what toilets it’ll be ok to use, it’s totally understandable. As a student nurse every new placement involves another coming out and this can be nerve wracking and emotionally difficult.

So here are five tips to survive coming out at placements:11049526_536723163136072_4031043654954708270_o

  1. Don’t feel you have to out yourself immediately – there is no need to introduce yourself as Emma the lesbian and you shouldn’t feel under pressure to do so
  2. But also don’t feel you can’t come out, everyone talks about their partners and children and you should be able to do the same.
  3. You don’t have to tell everyone, it’s ok to just tell people in conversation and leave those who weren’t there to work it out for themselves
  4. If you have any problems or concerns talk to your AA, mentor or PEF, they are there to support you and you should never face any discrimination on the grounds of your sexuality or gender identity
  5. Don’t be embarrassed, be proud of who you are, you have a unique life experience which will be valuable to you in nursing

The University LGBT society have lots going on, although it won’t always be possible to make their Wednesday group they also have things going on in the evenings and weekends. In Manchester you’ll also find the LGBT Foundation who have lots going on and can offer lots of support.FENT__1432160698_here-if-need-us