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

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.

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. 

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!

Hello from the other side…

We’re delighted to share this guest blog from Lizzie, a fourth year Bachelor of Nursing and Midwifery student from the University of Queensland, Australia. Lizzie shares her incredible experience on exchange at the University of Manchester where she is completing her final nursing placement in A&E at Manchester Royal Infirmary:

“Hello… Can you open your eyes please… What’s your name? Do you know where you are?

My name’s is Lizzie, I’m the student nurse looking after you. How can I help?”

Welcome to the adrenaline packed, electrifying, exhausting and incredibly humbling world of Accident and Emergency. I’m one of two UQ final year Bachelor of Nursing/ Midwifery student’s fortunate enough to have the incredible opportunity to go on Exchange to the University of Manchester, and complete my final Nursing Undergraduate Placement in A+E at the Manchester Royal Infirmary.

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I can’t believe in just under three weeks I’ll be finished my nursing degree! When I was little I always dreamt of being able to help people with my hands, my heart and my brain. I actually have come to feel so at home in the hospital – nursing has fit me like a glove. I love to learn, I’m a people person, but most of all I feel such a sense of satisfaction when I know I’ve made a difference. That’s why I’m excited, and proud to (almost) be a nurse.

I’ve been in the UK for 3 months now. Words can’t describe some of the things I have seen, how much I have grown personally and professionally, and how much I love it here – but I’ll give it my best.

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A+E is a never-ending puzzle. In comes a person with a list of symptoms, and (in the time constraints of the National Health Service’s 4-hour max wait times) you assess, stabilise, gain a history, conduct tests, perform interventions, monitor for the impact of these interventions, and then either refer them to a specialty or (hopefully) send them home. The true skill comes in managing many patients simultaneously – yet still treating, valuing and respecting each as an individual.

While every shift is an adventure – here are some of my highlights:

In A+E when there is a really critical person about to come in we get pre-alerted by a call from the Ambulance service to a “Red Phone”. The Nurse in charge takes the call, and then alerts the department over the loud-speaker – “Red Standby, Adult Major Trauma – ETA 5mins”.

One of these “Red Standbys” was a motorbike vs car head on collision, resulting in fractures to the patient’s femur, hip, wrist, and back… I got to look after and stabilize the patient, and follow them through to the Orthopedic Trauma Operating Theatre. The surgeons and theatre nurses were so kind, they not only talked me through the 3 operations, but they even let me scrub in so I could stand right next to the surgeon as he used metal rods, plates and pins to reconstruct the patient’s broken bones.

I have been actively involved in eight cardiac arrests (one was on my first day – but that’s another story). I’ve helped wheel a patient down the hallway while they were actively receiving CPR, and get them to the “Cath-Lab” where under X-ray guidance surgeons were able to guide a wire up the patient’s femoral artery, and use a stent to reopen the diseased blood vessels of the heart, and save his life.

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I have been blessed with a plethora of opportunities to learn – just over a week ago I traveled to Chorley to complete a simulation training day in “Out of Hospital Emergencies” with the Paramedics and Army Reserve. I’ve worked with an advanced practice nurse running a Community Clinic for Chronic Diseases, and have done home visits with a GP for the day – visiting some of the sickest home-bound patients.

Just yesterday I got to ride in an ambulance for the first time as we transferred a patient to a specialist hospital for neurosurgery. The patient was critical, so we traveled on “blue lights”. The paramedic crew were amazingly skilled, calm and good at balancing as we tore down the highway.

Manchester is a beautiful city to explore, and the rest of the UK is so close that I’ve being doing my best to see as much as can on my days off. So far I’ve day-tripped to the Lakes District, spent a weekend in Bath visiting the Roman baths and Stonehenge, seen some stunning castles in Wales, and travelled to Dublin for St. Patrick’s Day!

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There are some exciting opportunities on the horizon – in my final week as a student nurse I’ll be attending a conference in London and on shift with the London Ambulance Service.

I have been so lucky to have worked as part of an incredibly supportive team and mentored by inspiring nurses and doctors. I won’t sugar coat it – I have seen some heartbreaking things (as is the nature of Accident and Emergency), but I wouldn’t change a thing. I’ve found my calling – caring for people when they are most vulnerable. Be that at the beginning (as a student midwife) or at the end (as a student nurse), it’s my privilege to love, support and provide dignity. Not as a healthcare professional, but as one human being caring for another human being.

I have learned there is never a situation in which a non-judgmental ear, a hand to hold, and kindness won’t help.

I’ve realised how precious every moment is.