Behind closed doors: a student nurse in general practice

When I first considered nursing as a career, it wasn’t the adrenaline-filled excitement of A&E or intensive care that attracted me; neither was it intricate technical knowledge of theatre nursing or the busy variety of working on a ward. From the outset, community-based or practice nursing had always been my ambition. Maybe I’m slightly odd, but I love chronic conditions and the idea of helping people to manage those has always been appealing. I was also attracted by the autonomy of practice nursing and opportunity to work towards advanced nursing skills like prescribing…and I can’t lie, the lack of nights or weekends didn’t seem too bad either.

Research online suggested that I would need at least two years experience, preferably in A&E, or even a masters degree before moving into general practice. I wasn’t put off, but as a mature student it felt like there were a lot of hurdles to overcome before I could realise my ambition of becoming a practice nurse. I didn’t think for a moment that I’d spend time as a student nurse in general practice – so when I tentatively checked our placement allocations earlier this year, I was over the moon to find out that I’d been placed in a GP surgery nearby.

My mentor and the whole nursing team at the surgery couldn’t have been more welcoming. I discovered that I was their first nursing student and that the surgery is leading a project locally to encourage more GP surgeries to offer placements to student nurses. Like other areas of nursing, there have been difficulties recruiting practice nurses for a number of years, partly down to current practice nurses reaching retirement age, alongside fewer newly-qualified or experienced nurses choosing practice nursing as a career. As such, surgeries like the one I was placed at want to promote general practice as an attractive place to work; they see placements for student nurses during their training as a key part of that strategy.

Over the 12 week placement I got a real insight in the role of the practice nurse. My mentor, who was also a prescriber, led on the management of chronic conditions like hypertension, asthma and COPD, which encompasses advanced assessment skills, prescribing and lifestyle advice. This was on top of bloods, smear tests, contraception advice and of course, lots of injections; a workload shared with another skilled nurse who also took care of all child immunisations and travel vaccinations. They both worked closely with an experienced care support worker who took care of ECGs and spirometry, among many other things. Meanwhile, an Advanced Nurse Practitioner also based at the surgery leads on emergency consultations, seeing everything from chest infections to mental health crises. It was fantastic to see the varied role of the nurse in general practice and just how valued they were by patients.

The first few weeks of my placement were spent observing however as the placement progressed I was encouraged by my mentor to start leading consultations under her supervision. This was nerve wracking at first, but my confidence soon grew. I was eventually given my own clinics to run, taking on straight-forward asthma reviews and blood-pressure checks. It was fantastic having my own room and calling patients in from the waiting room. I loved talking to people about their health, explaining how their medication works and making a plan together that we hoped would help them better manage their condition. The most rewarding part was seeing patients return. One man said his life had been transformed by a steroid inhaler I had encouraged him to start using, saying that he no longer felt breathless or worried about his asthma. The opportunity to get to know your patients and equip them with the tools and knowledge to improve their health and quality of life, has to be one of the best parts of practice nursing.

The pressures on GP surgeries were clear to see, as they are in many other parts of the NHS, however my time in general practice revealed just how crucial practice nurses are in supporting the everyday health needs of individuals. Practice nurses are highly-skilled practitioners in their own right who make a valuable contribution alongside GPs and the rest of the team in a surgery. Hopefully more GP surgeries will start taking on student nurses during their training so that more can gain experience in this often-overlooked area of nursing. Of course it’s not everyone’s cup of tea, but I loved my time in general practice and feel that student and newly-qualified nurses have so much to offer to this area.

We would love to hear your views on nursing in general practice – is it a career path you would consider as a newly-qualified nurse? Share your thoughts below!

What is a [blank] ward like?: Post 2 – Community Nursing

StateLibQld_2_115064_Interior_of_the_Mater_Misericordiae_Hospital,_Brisbane,_1914

Mater Misericordiae Hospital, Brisbane 1914

The first thing I wanted to know when I saw my placement allocation was what on earth being ‘in the community’ might entail. I knew that we would be caring for patients in their homes, but beyond that…

What kind of things would I get to see/do?

What sort of nursing goes on?

What is the day-to-day like?

In this series of posts, I will briefly describe the kind of activities I encountered on each of my placements so far.  Although all placements will have a slightly different set-up and slightly different ways of doing things, hopefully this will give you a better mental image of what you will be walking into on your first placement day.

District Nursing:

My second placement was with the district nurses (DNs) in a relatively deprived area of Greater Manchester. The DNs were based in offices at the back of a local GP surgery. They met here in the mornings before going out to people’s homes and returned here in the afternoons to complete paperwork and get ready for the next day.

 

The patients we saw to primarily needed wounds redressing. Some were short term patients who had surgical wounds that would need the ‘clips’ or metal staples removed in 7-10 days after their surgery. Sometimes these patients ended up becoming longer term cases if there were complications with their wound healing. Other patients were long term/permanent and these often had non-healing venous leg ulcers that needed regular redressing. We also saw patients who were prescribed insulin for their diabetes and needed continuous support with administering the subcutaneous injection. Other less common visits I experienced included post-surgical prophylactic low-molecular weight heparin injections for prevention of venous thromboembolism, line flushing for central lines used to administer chemotherapy, cancer patient comfort visits/check-ups and end of life palliative care for syringe driver maintenance.

 

Our days consisted of meeting at the GP surgery in the morning around 08:30-09:00. If you’ve previously been on a ward that might seem like a late start for nursing, but the DNs would usually make a few visits to regular patients needing insulin on their way into work from home. Once in the office, they would pick up their list of patients for the day that had been allocated the previous afternoon. After reading through the list to see what their day would entail, the DNs would pick up any materials they needed from the store room (e.g. sterile field wound dressing packs, specific dressings they suspected they might want for a particular patient). Then, considering the location of each of the visits, they would decide who to see first, second etc and set off for their first visit around 09:30.

 

Once at a patients home, the DNs would enter and ask for the patient’s notes file that was kept in their home. If the nurse was familiar with the patient and vice versa, they would probably be comfortable with what they were there to do, quickly check the patient notes and get on with the task. If they hadn’t met the patient or perhaps the patient’s status had recently changed, the DNs would take a moment to discuss this with the patient and decide on the best way to approach the visit. Some visits took 5 minutes (e.g. injections), some took 30-45 minutes (e.g. extensive leg wound dressings or cancer care visits).

 

Some days the DNs would have 5-7 patients to visit. Other days there would be 10-15 visits. This depended on patient need, any unscheduled visits (e.g. a patient rings in to say that their dressing has fallen off or they are worried about something and need to see a nurse) and the estimated length of each visit.

 

Once the last patient of the day had been seen, the DNs would return to the GP surgery offices to complete paperwork before finishing. This included filling in patient visit details on the computer, checking emails, responding to any phone calls that had arrived while they were out, obtaining/writing any prescriptions for dressings necessary and faxing this information to the pharmacy.

 

Sometimes, the DNs would have ‘clinic appointments’ in the afternoon at the GP surgery. These were for patients who were transitioning from being housebound to being more mobile but who still needed nursing attention for say wound dressings. Asking the patient to come into the surgery, where possible, encouraged them to mobilise and become more independent. It also meant that the nurses could save on travel time and complete their paperwork in between waiting for patients to arrive for their clinic appointments.

 

Again, every community team is slightly different, but in general, these are the kinds of activities that will be going on around you. As always – be sure to get involved as much as possible!

 

See here for a blog post on the use of Aspetic Non-Touch Technique (ANTT) within the community.

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.