The next chapter: Starting a new academic year

Last week I was going to post a blog about how I was feeling about starting third year but feeling terrified was my overriding feeling, and no one needs that kind of negativity, right?! I decided to wait until my first day back to write my feelings. So, here goes.

Firstly, I am exhausted! Woah, information overload! But not too exhausted to write to you lovely bunch so may be exaggerating a little! Today we were afforded an incredible opportunity to speak to trusts from all over the country and learn what they want from students applying for jobs. I felt anxious entering the room but left university feeling inspired. I feel like I can be anything I want to be! The trouble is, I don’t know exactly what I want to do yet. I know what my key interests are and know that I want to consolidate my learning in my first role as a qualified nurse but there isn’t currently a specialism screaming out at me. That’s okay though, isn’t it? Here I am referring to this as ‘trouble’. Pardon? This is a PRIVILEGE!

I received encouraging feedback today from representatives from different trusts, as well as from my colleagues. We’ve talked through the benefits of keeping a professional profile and throughout that discussion I flicked through some of my written feedback… Wow! I had forgotten about some of these kind and inspiring words.

I’ve complied a little list of pick-me-up reminders influenced by today’s activities and how I was feeling just last week. I thought I would share them and maybe you might take something from them too:

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  • Try to recognise whether I’m thinking rationally
  • Read over feedback and realise my potential
  • Focus on the positives. I have another year of study and a future of continued professional development – even my weaknesses can be positives!
  • Pat myself on the back. I have shown myself I can do so well already
  • Remind myself why I wanted to nurse and reignite those drivers
  • Get organised. Taking some time now for good planning will save a lot of time and worry in the long run. Time to get everything in that shiny new diary!
  • Take some time to digest ‘information overload’ – break it into more manageable pieces
  • Remember that it is okay to feel a bit overwhelmed – I’m not the only one feeling this way. I must remember to be good to myself and do something that is not nursing-related from time-to-time… Starting this weekend!

Now I approach this academic year feeling like I can achieve anything if I work hard enough. I’ve got this! And you have too!

Special thanks to today’s speakers, exhibitors and organisers for a motivating and informative day.

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Padding out your Portfolio

As a student nurse, you are expected to keep a portfolio/professional profile to remember all the amazing things you’ve done, and it’s a good way to show why an employer should hire you.

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My portfolio baby (complete with an unfortunate stain)

Alongside lots of other things like reflections (see Natasha’s blog post), certificates are a good thing to show how great a student nurse you are. Certificates in your portfolio are the equivalent of gold stars on a chart. You’ve really earned them, and they look pretty.

You can get these wonderful holy grails by attending workshops, training events, and educational lectures through university or placement. For example, a few weeks ago I attended the clinical skills event organized by the HEAL society (Healthcare Alliance). And it was amazing!

Alongside with healthcare related students, we learnt skills such as a swallow assessment, how to use an Ophthalmoscope, Neonatal resus, how and why crushing tablets is necessary, and I got to interact with a simulation man! These activities were chosen because they are quite specialized activities, which you might not normally get the chance to learn about. So events like these give you the chance to get that practice in! Plus, most of them were taught by fellow students (speech & language therapists, ophthalmologists, medical students, nurses and midwives!), and peer education is always great! The free pizza was also a bonus..

It’s super easy to get involved with this kind of stuff- you just have to keep an eye out! Most of the events are advertised through your university email, but they can also pop up through word of mouth. So idle chit-chat with your course mates might just lead to some professional development!

Writing in Patient Notes

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Documenting patient care can be a daunting task.

  • What did I do today?
  • Do I really need to write all of this down?
  • Is what I’m writing making any sense to someone else reading it?
  • Have I kept any personal judgements out of the notes? (e.g. patient is friendly)
  • Did I use ambiguous terms like ‘ok’, ‘good/bad’, ‘high/low’ without giving more specific information? (e.g. ‘pulse low’ versus ‘pulse low (39)’)
  • What are the things that other members of the Multidisciplinary Team (MDT) need to know about the care I gave my patient today? (e.g. how much is too much information?)

Document as you go along or in one large paragraph at the end of the shift

It is considered good practice to write about care as it happens so that you are less likely to forget or incorrectly document any care that has been provided. In practice, however, you may find it difficult to set aside time to write in bits and pieces throughout the day. Most nurses tend to record important clinical decisions, test results, scores etc. on their handover sheet as they go and then document it all in one sitting later on in the shift. You will gradually find what you are comfortable with and what works for you on your ward. Just remember that documenting care accurately is very important. You will often hear staff say that documentation is your safeguard against lawsuits or the NMC questioning your practice. I prefer to consider the patient’s situation first and say that accurate documentation benefits your patient immensely by keeping them safe. If the rest of the team is up-to-date with what care the patient has already received, what stage they are at with mobility, continence, wounds etc. then other staff will be better equipped to plan their own further interventions.

Different types of documentation systems

You’ll see lots of different systems for documenting patient care. Every ward/district/trust does it slightly differently.

Among the possibilities you will see are:

  • preprinted care plans that just require a signature and may have a free text set of blank lines on the back to note anything out of the ordinary,
  • reams of blank line sheets just on their own – usually called ‘continuation sheets‘ – where all the care is documented in paragraph style,
  • separate styles of continuation sheets for nurses and medical staff where doctors, physiotherapists (physios), occupational therapists (OTs), etc. will document their patient visits on one type of sheet with blank lines and nurses will use another slightly different type with blank lines,
  • places where all staff write on the same sheet with blank lines and nurse, doctor and OT notes will all be mixed up together with or without preprinted care plans.

Writing in preprinted care plans can seem easier as there is a defined structure that prompts you to provide the pertinent information. It can also be frustrating when you have something to add that doesn’t quite fit in any of the care plans as they are often rather specific. Some nurses will tell you that they ignore the small areas for free text on the preprinted care plans and simply rewrite everything in a main continuation sheet of nursing notes. Again, you will find what works best for you and your workplace. There are arguments for and against any method as well as arguments for and against an NHS wide standardisation and a ward specific way of documenting. This is ongoing and you’re likely to see as much change in your job once qualified as you have done during your training!

Keeping it accurate, concise and comprehensive but relevant

Easier said than done, right? You know what you have accomplished on the shift, but to condense everything down into a smallish paragraph can be tricky. It is definitely a good idea to start getting a pattern to what you write which will help you avoid missing out any care given. I have seen people who write chronologically, some who write according to body systems (e.g. anything to do with respiratory first, then anything to do with cardiovascular, then renal etc.) and those who have their own set pattern.

Documentation Example

This is an example of how you might consider setting out your notes. It would be written in paragraph form, not bullet points as gaps should not be left on lines to prevent additions to your writing after you have signed it. You will find this is something nurses stick to but medical staff do not.

  • Written retrospectively
  • Patient care taken over at 07:30.
  • Initial observations completed, EWS = 1 due to low systolic (93/51). Monitored over next hour and currently EWS=0.
  • Patient reports no pain/nausea.
  • No shortness of breath. SpO2 and respiratory rate within range. Patient on nasal spec (2L O2).
  • Patient required some assistance x1 with wash this morning.
  • All pressure areas intact, SKIN Bundle completed.
  • Passing urine but bowels not opened as of 13:30.
  • Diet and fluids taken.
  • Anti-hypertensives and diuretic withheld due to low systolic, all other medications administered as prescribed. Patient encouraged to drink fluids. Medical staff informed.
  • Patient mobilising independently with frame – advised to request support if required.
  • TED stocking (large) removed and reapplied after 30 minute rest.
  • Surgical wound (right knee) dressing dry and intact. No signs of inflammation/infection.
  • Recent test results: Hb 132, Urine dip = NAD, MRSA negative
  • Section 2 sent
  • All care explained, patient fully capable of expressing needs.
  • Water and call button in reach.
  • Patient reports comfortable, no concerns at present.

The majority of this is pertinent to most patients. Some will be shorter if, for example, their EWS=0 you would just put ‘Initial observations completed, EWS=0.’ Or if they were on room air instead of nasal cannulae you could say ‘No shortness of breath. SpO2 and respiratory rate within range on room air.’ It is difficult to avoid repeating documentation, for example, I have not included VIP scores for a cannula as this more than likely will have its own separate sheet. Feel free to include it yourself. You will also no doubt think of something else I could have included and this is the nature of documentation. I guarantee you that as soon as you write the final line and sign your name you’ll remember something else to include and end up adding one more line at the end and signing all over again.

What is important?

Well everything and nothing really. Different healthcare professionals will tell you that they only want to hear about x, y, and z when others want a, b, and c. The best you can do is present the information in an organised fashion that clearly and concisely states the contact you have had with your patient. The information should also help staff to notice developing patterns. For example, if a patient has not opened their bowels for a few days and you notice this reading through the last entry, you may wish to discuss this with the medical team to see if an appropriate laxative can be prescribed. Or if a patient continually reports severe pain first thing in the morning, understanding why this is the case and discussing possible changes to their available breakthrough analgesia would benefit the patient greatly.

Remember this is a learning process and no one size fits all. Keep the safety and quality of your patient’s care at the forefront of your mind at all times and you will be fine.

 

New Placement Resolutions

In late February I’m a bit slow off the mark for New Year’s Resolutions, but as us 3rd years start our Leadership & Management placement tomorrow I thought I’d write (in no particular order) about some ‘placement resolutions’ that I’d like to start doing  or things I already do that I need to keep up. For the more organised amongst you this is probably second nature but I feel like I would have appreciated these tips when I was in first year! I’m an Adult nurse but hopefully these things should be relevant to all fields so I hope you find this useful!

  1. Batch cook lunches for the week: I’m terrible for overeating when stressed or short of time and often find myself eating fas
    t food or ready made sandwiches on my break, leaving me feeling bloated and lethargic for the rest of my shift. This time around I’m going to make an effort to save money and stay healthy by pre-preparing food to bring with me to placement. It’s also a good idea to have some emergency cereal bars in your bag for a shift when you need an extra boost of energy!
  2. Pack your bag the night before: I’m really not a morning person, especially in winter when your alarm goes off at 5am in the dark and you feel like you don’t see daylight for weeks! Knowing that all my stuff is ready to go and all I have to do is fill a flabigger pocket gifsk and eat some toast like a zombie, makes it just that little bit easier to get out of bed. This sounds obvious but I try and put all my placement bits and bobs in a box all together- it’s brilliant to avoid rushing in the morning when the night before you’ve come home from a long day and thrown your name badge, ID card, fob watch, bus pass etc.. on the floor with your uniform!                                                                                                           Ps. Invest in a good travel mug! It’s the most useful thing I bought in 1st year!  Kim also has a great blog on preparing for placements (‘Pre-placement necessities’
  3. Always double check your PADIt’s actually embarrassing how many times I’ve had to go back to placement after finishing to collect a missing signature. Save yourself a trip and learn from my mistakes!
  4. Speak up sooner with problems: On a previous placement I had an issue, I raised this on the ward and also with the PEF, but unfortunately it wasn’t dealt with in the way I’d hoped and started to affect how I felt about going to that ward and was really getting me down. It took me a while to bring this up again with my AA, and realise that it wasn’t a satisfactory solution to the ward problems. Remember if you’re unhappy on placement and need to resolve an issue, don’t hesitate to ask! Usually PEFs are fantastic and your AA will always be supportive but if they don’t know about the problem, they can’t help you! If you need more information about where you can go to for Support on Placement check out the Placement Survival Pack.11535296_10153989835585820_926530824_o
  5. Take notes: I try and jot down things I’m not sure about to look up later, for example; a new acronym or a condition I’ve not heard of before. Then it reminds me to look it up later and jot it down in a pocket notebook. It’s also really handy to keep a list of useful numbers in.
  6. Background reading: If I’ve been allocated to a ward with a speciality I’m not familiar with I always try and read a bit more around the subject for example; common conditions, A&P/pathology behind it, main drugs I’m likely to see on this ward etc.. However if I’ve done this in some free time around allocation day it might be a long time before I actually start there so I’ve also started jotting these down in my notebook.
  7. Make a timetable: One of the hardest things about nursing degrees is balancing your time when you have so many extra things to do whilst you’re on placement. When you’re working you can just come home and that’s the end of your day, you don’t need to worry about working on that essay or writing some reflections when all you want to do is collapse in a heap on the sofa! I’ve tried to make myself a timetable as soon as I get my off duty, to try and organise my time around shifts so I don’t leave everything last minute- sticking to this however is another matter! I’d also say that if you feel your workload is too much, you’re not coping or there’s other things going on in your life that’s affecting how you feel- go and speak to your AA about it, don’t struggle on alone!

I hope you find some of these tips useful, got any of your own you’d like to share or suggestions for new posts? Please get in touch below!

 

Placement and Social life – The student nurses’ finest Juggling act

After a Long-day in placement it is essential to unwind

After a Long-day in placement it is essential to unwind

Being a regular student I’d say is equal parts social as it is educational. We however, are not regular students. This is a difficult concept to get to grips with as we are getting a degree at the end of the day and we do go to the same University as the others but we are student nurses so our three years are social, educational and practice based.

I won’t lie, there have been times I’ve missed out on an event or two because I’m starting placement the next day at 7.30 or because of the extended semester for example but you completely forget about the time you couldn’t go to Juicy at Joshua Brookes because you’re too busy telling everyone about the time you pulled out a 2 foot long chest drain or when a patient stopped you in the street and thanked you for your hard work.

The Squad

The Squad

I play Women’s Rugby for the University which involves various training sessions a week, fitness on a Saturday morning and Games pretty much every Wednesday (and vital socials on Wednesday night). Missing placement hours is not an option as it’s a 100% attendance course, however being clever with your off-duty is completely allowed. My 2 day placement was scheduled as a Thu-Fri however sometimes I would need the morning to remove the last of the face paint (Socials are always fancy dress themed) so I would request to be on a late shift or would work on a weekend.

The key here is communication. If your mentor is OK with it and you’re not falling behind on hours then it will keep everyone happier in the long run if you don’t compromise on your studies or your social calendar. So invest in a good diary and get planning, the sooner you plan the easier life becomes… Trust me.

Commentary: “If you need anything just use the Buzzer…”

Firstly, I would like to say thank you to Tasha for her thoughts on call buttons. I think this is a very important topic in terms of understanding patient need and attainable levels of comfort.

There is a reasonable amount of research out there exploring patients’ perceptions of the ‘busy nurse’ and how this changes their willingness to ask for support as well as what they value in nurse-patient communication (see McCabe, 2004 for an excellent introduction).

I think it is always worth keeping in mind that what may seem trivial to us might be something that is far from trivial to our patients. Taking your slightly colder water jug scenario – to a mobile individual who can get up to get their own water whenever they want and who feels relatively in good health it may be rather trivial to want colder water. But to a patient who may be feeling nauseous, overheated, uncomfortable and is currently bed bound – that cold water may mean a great deal. I realise that it was a comment made in jest but I also think you hit on something: patients are in an unfamiliar and ultimately uncomfortable environment and this discomfort will manifest itself in different fashions and lead to different patient responses.

Hospital stays take patients out of their own environment and place them in close proximity with other patients at a time when some or none of them may be feeling particularly well. Then to add insult to injury we ask them to do things such as have personal conversations about their care and condition or use a commode with nothing but a thin curtain between them and a dozen other individuals. As much as we try to preserve the dignity of our patients and attend to making their experience positive, I can’t help but think how excruciating I would find being admitted to hospital myself. Add to that the fear of upsetting a nurse who has labelled me as calling ‘unnecessarily’ for an ‘outrageous reason’ when my world has been reduced to revolving around the next mealtime, managing my pain and whether I need the toilet or not.

Of course there will be times when we realise we are dealing with a patient who is calling for an element of attention rather than just water. But maybe that attention is just as important in terms of the nursing care that we can provide. Have I reassured my patient sufficiently? Have I answered all their questions? Have I promised to do things previously and then forgotten and hence lost some of their trust in me as their nurse? Have I fully taken their immediate psychological health into consideration as one of my nursing goals for their care?

I would say that there are things we can do during our not-so-busy moments such as making a point of checking in on them rather than waiting for a call button to ring. That little bit of extra support may alleviate some of their concerns and decrease their use of the call button – thus leaving us in a position where we can trust that if the button goes off we know it will be something more serious.

McCabe, C. (2004) Nurse-patient communication: an exploration of patients’ experiences. Journal of Clinical Nursing, 13(1):41-49.

Off-duty – The folder that conveniently tells you when you’re on duty

Every placement, be it community or ward will have an Off-Duty of sorts (some are actual folders and others are being digitalised) which is the schedule for that placement’s staff including us as students. These should be released at least a week in advance to allow you to make travel plans etc. but that sometimes needs to be chased up.

Generally you work the same shifts as your mentor but if this isn’t possible it should be identified who you’ll be working with to make sure you’re supported and you know who to go to if you have an issue whilst you’re in practice.

Different years have different requirements for how you spend your hours on placement which can affect the off-duty, for example in 2nd and 3rd year the NMC requires you to have evidence of exposure to 24 hour care (aka night shifts) but there is no longer a specific necessity of a certain number of shifts. However you should consult your course handbook for year on year updates of the requirements from the NMC and the University.folder-626334_640