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Student Nurse Blog Year 3 - Week 19

January 9th 2007

09/01/2007

Year 3 – Semester 5 Second clinical placement.

This semester we have had two shorter clinical placements instead of one long one. This is to accommodate those students who have organised ‘elective’ placements either abroad or somewhere within the UK.

I started my second placement Tuesday of last week (2nd Jan 07). It is on a ‘Rehabilitation’ ward, which is also classified as care of the elderly. I know the ward well as it is in the old hospital (which also hosts rheumatology and acute psychiatry) based on the same site as the new hospital. There were five medical wards in this hospital (including rheumatology), but two have been closed down due to financial constraints, so now we only have three. There were two acute psychiatric wards, but one has been closed – again for financial reasons – so now there is only one psychiatric ward. (Will everyone please stop closing hospitals and wards, it won’t stop people being acutely ill!). This has put an extra strain on the beds available within the wards. In addition to this, when the new (acute) hospital hits a bed crisis (quite frequently) and needs to discharge medically fit patients (who are blocking beds due to social or rehab placement reasons) they tend to get sent over to these medical (non-acute) wards in the old hospital.

I had already visited the ward a couple of times prior to commencing my placement, so had been given a tour around and shown where the emergency equipment was kept. During the first week I worked the same shifts as my ‘active’ mentor, the ward manager. I spent most of the time working with the Health Care Assistants doing the morning bed baths, assisting patients with their hygiene and dressing needs, mobility and toiletting. As it is a rehab ward, the patients generally tend to spend more time on the ward (anything from a couple of weeks up to several months – I’ve been there just over one week and only seen two discharges, two admissions and one death), so I felt it was important to get to know the patients during the first week. By doing essential nursing tasks in this first week it gave me the chance to practice and improve my assessment skills – such as assessing skin condition and pressure areas, psychological and emotional state, urine output and other toiletting patterns, and the patients’ level of mobility. This gave me chance to see how far they were developing along the rehab program and the progress being made. It also gave me a chance to talk to the patients’. This allowed me to get to know them, their mental state (i.e. disorientated at times, mentally alert, reduced cognitive functioning, etc.) and any anxieties or worries they had regarding their future care (either with returning home or placements at medium to long term Intermediate Care Units in the Community).

During this time I also carried out a lot of blood glucose measurements (bgms) and observations (temp, HR, RR, BP, SpO2). There was one patient who had recently had her PEG feed regime increased and her bgms were very high in the mornings (around 30mmols), decreasing throughout the day to around 17mmols by the evening. I was able to have quite a lot of input with the dietician when she came to review the patient, along with the diabetic nurse specialist when she also reviewed the patient. This allowed me to pass onto the team the plan of action decided during each new review (which had been to reduce the feed rate and run it over a longer period of time to see if this was effecting the bgm levels – as an increase in insulin had failed to improve the situation over a 24hour trial period).

I was also able to talk to a couple of the doctors during the end of the first week with regard to some of the patients under their care. Much of it related to things such as progress made with physio, general condition state, and oral intake. It was the first time since December 2005 (when I finished my third placement – semester 3, year 2) that I had had a ward based placement. My fourth placement was out with the District Nurses in the community and my fifth placement was the cancer/palliative care pathway placement (working in clinics, outpatients, and visiting patients on the wards). However, despite not working on a ward for just over a year, it wasn’t long before I had settled in to the ward routine and environment.

This week (my second week, commencing Monday 8th) I have continued to do essential nursing skills at the start of my morning shifts and also moved on to some patient management tasks. This has involved chasing up reviews from doctors and orthopaedic teams, making referrals and liaising with other members of the health care team regarding rehab. The problem I have with this placement is that it is so short. Although my previous placement was short we were allowed to submit our final clinical placement practice interview forms during the final week. However, this placement is only six weeks long and the final interview forms need to be submitted at the end of the fourth week. However, during my fourth week I am not here, as I am doing my final weeks rotation for mental health (part of our EU directives). So for the whole of that week I will be working on an acute psychiatric ward. This means that I need to do my final interview by the end of the third week. So I have next week left and then at the end of that week I will have my intermediate and final interview at the same time!

So during these first two weeks I have tackled the essentials of hands on nursing, such as mobility, hygiene, toiletting, wound care, observations assessments (ranges, physiological, psychological and emotional changes), etc.. I am hoping that during the third week I can then tackle drugs and patient management (admission, discharge, referrals, MDT meeting, etc). I am not too worried as I have three more days left for this week and there are several patients who need dressings changed (thus tackling my wound care, aseptic technique and assessments competencies), there are also plenty of other things I can get done before Friday. All the nursing staff (qualified and auxiliary) seem more than happy with my level of knowledge, performance and nursing care.

I have fitted in well on this placement and find everyone very friendly and accommodating. In some ways I find it very relaxed (even when it’s busy) compared to the acute medical and surgical wards I’ve worked on both at this hospital and the one in Somerset. However, it does seem slightly busier than the ‘rehab’ ward I did a couple of shifts on at the hospital in Somerset.

I am hoping that during the fifth and sixth weeks I can spend time having my own patients (around six) and also spending time with the rehab OT and Physio team, so I can learn more about what involved with the rehab process with these type of patient and the other resources available in the community for further long term rehab support.

Well that’s about it for now. I will blog again either later this week or early next week.

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18/01/2007

Hi all, sorry I haven’t updated my blog as regularly as I usually do, but I’ve been very busy over the last week or so. Placement is going brilliantly, I’m doing lots of clinical skills and management, as well as care planning for the patients. I have my intermediate and final interview tomorrow, so wish me luck! I had an interview this morning at a private BUPA hospital for a position of Bank HCA on the ward and in outpatients, I’ve got the job, but won’t start yet as I have paperwork to complete and a CRB to do (Why do we now have to do a CRB everytime we start a new job, even if we have one only a few months old, it’s crazy?!). The people at BUPA know that I am a student nurse and qualify in August. I told them that I would be moving to Salford to do another three years at university and, if things worked out at the BUPA hospital, I would be interested in transfering to the Manchester BUPA hospital when I move and working on the bank as a staff nurse. They thought that this would be a good idea.

I start my final week psychiatry/mental health placement next week on the same ward I did my first week. I am looking forward to it. will let you all know how it goes.

Anyway, got to go, on a 2-10pm today and still lots to do before my shift.

Regards,
Matt

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19/01/2007

Well guys and gals, today I wasn’t able to do the intermediate and final interview. It was far too busy on the ward! It was that busy that I didn’t even get to have a lunch break, I just took ten minutes out to eat my sandwiches. That’s something I haven’t done since I worked on wards in the acute hospital.

Hope you all have a great weekend. I start my mental health placement next week for one week, the final week for my EU directives. I’ve got my intermediate and final interview on the Tuesday morning. I’ll let you all know how it goes.

Matt

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24/01/2007

Semester 5 – EU Directives – Mental Health/Psychiatry placement

I started the second week, and final part, of my mental health/psychiatry EU Directives placement on Monday 22nd January 2007. The first shift was an 8am – 4pm stint. The placement was on the same acute psychiatric admissions ward that I had done my first weeks mental health EU Directives.

Although I was still familiar with the ward, the shift started with a tour around, showing me where everything was. I was then issued with my personal alarm. After that I was given a quick overview of the ward philosophy and policies. Since I had last worked on the ward a new strategy had been brought in known as ‘Refocusing’.

Refocusing aims to improve the standard of care and patient satisfaction. This means that the patient receives a more focused admission based on their needs. They will be given an opportunity to express their opinion about their care on the ward and will be provided with a structured day that will engage them with nursing staff. This will happen by providing predictable, well-managed and clear structures on the ward. By introducing and maintaining appropriate ward boundaries. Developing the means to provide high levels of therapeutic engagement and to promote respectful, joint relationships between staff and service users and their significant others and to ensure that service users and those who advocate for them work together with staff towards a common aim extended within the refocusing project.

Everyone I have spoken to, both patients and staff have found the ward boundaries and expectations very fair and reasonable. I think that the idea of refocusing is fantastic. Especially from my previous experience of acute psychiatric admissions wards. I have worked for a very short time on two other such wards prior to my nurse training (around 2001) and found that – at that time – patient and nurse interaction was very limited with no real structured day for the patients (please note that these two psychiatric wards were not in this area and were in two locations much further south of my current location).

If anyone wishes to see a copy of the ward boundaries and expectations please feel free to ask and I can post them on this blog, or email them.

I was then given time to walk around the ward on my own and talk to some of the patients. Three of the patients on the ward had been on the ward during my first week’s mental health/psychiatry placement over a year ago. However, these three particular patients each suffer from long term mental health conditions which means that they occasionally relapse and become non-compliant with their medication, or they get better and again become non-compliant with their medication (because they feel that they no longer require it because they are better). This then means that they need to be admitted to an acute psychiatric admissions ward so they can be mentally stabilized and recommenced on their medication.

I spent a lot of the first day talking with the patients and getting to know them. Some of them were more engaging in conversation than others, depending upon why they had been admitted to the ward. Mid-morning I met up with the nurses again and they went through the weekly activities timetable with me. There was a newspaper group held each morning. This basically involved one of the nurses sitting with some of the patients in the dining room and talking about the contents of the newspapers. I joined in with that morning’s newspaper meeting, which lasted until lunchtime. I spent lunchtime reading through the notes for a couple of the patients that I had talked to that morning (the one’s that I had not known from my previous time on the ward). After lunch I spent some more time talking with some of the patients. Most of the conversation involved asking the patients how they were feeling, how long they had been on the ward for, why they had been admitted to the ward, past psychiatric history, any concerns that the patients had and how they felt they were coping. The responses I got from a large amount of the patients I spoke to were quite positive. A lot of the patients were happy to talk about their psychiatric illnesses or psychological conditions. Of those patients who had no insight into their illness, they were still happy to engage in conversation regarding their delusions or psychosis, which allowed me to gain equally beneficial information into their conditions.

At 3pm there was a scheduled ‘stress busters’ session, which was one of three weekly afternoon sessions run by the Occupational Therapist. However, she was off sick this week, so the session was run by one of the nurses. There are two acute psychiatric admissions wards that are joined together and share the same dining facilities. They also share the same planned activity sessions, such as ‘stress busters’. A total of six patients attended the afternoon session from both the wards. The nurse read out information on anxiety from an information pack, covering what anxiety was, what triggered it, the physical symptoms resulting from anxiety and then a question and answer session. I was able to give some advice at the end regarding the benefit of identifying ‘triggers’ for anxiety and learning and rehearsing relaxation techniques so they became a conditioned response in order to allow people to cope with anxiety provoking situations. I was only able to do this due to my psychology diploma and other previous training in counselling.

I found the first day very useful and extremely good. It allowed me to build good relationships with around half of the patients on the ward, as well as learn about the new techniques used in psychiatric wards regarding patient care and treatment planning.

My second shift was on the Tuesday, where I worked a 9am – 5pm shift. I was also supposed to have my intermediate and final placement interview for my clinical placement. This was due at 11am. I started the shift by joining in with the morning drug rounds again and talking with the nurse about some of the medication. I then spent most of the morning talking to several of the patients and expanding on the conversations I had with some of them the previous day. At 1050am I left the ward to go over to the medical rehab ward (also in the same hospital) for my intermediate and final placement interview with my mentor and ward manager. When I arrived at the ward it was absolute chaos (no change there for the NHS!). The first thing I saw as I walked onto the ward was the Matron running with an ECG machine. Whilst I waited for my mentor I revised some medications for my interview and helped out on the ward by answering the phones. At 1120am I started to become a little concerned, wondering whether my mentor was delayed because she was trying to find somewhere to park, or had forgotten about it or was unable to make it due to other clinical commitments. At 1140am I decided that I would go back to the psychiatric ward, to save wasting anymore time. I left a message with the ward clerk and one of the staff nurses asking my mentor to radio page me or phone the psychiatric ward when she came in for the late shift. Then I left my radio page number on the front of my practice placement competencies folder. I went back to the psychiatric ward and read up some more in the office on assessment rating scales.

During lunch time I read up some more on the assessment scales and then ate my sandwiches in the dining room, whilst talking with some of the patients. In the afternoon I spent more time talking with some of the patients. There was one particular patient who had been admitted as being psychotic and suicidal. He was in a particularly low mood and I spent a good time over the two days talking with him. On several occasions I had managed to raise the mood (if not only slightly) with three of the patients I had talked with during my time on the ward. I spent a good fifteen minutes talking with this male patient and, as with every other patient I talked with, I explained that I was a student nurse and was not trained to the same level as the psychiatric nurses on the ward. At the end of the conversation with this male patient, he thanked me for our conversation and said that it had helped him greatly, his mood had certainly improved. After that I attended the weekly ‘community meeting’, which is the same as the old style weekly ward meetings, but developed more around the new ‘refocusing’ philosophy.

Things started to get a bit more exciting after the meeting. One of the patients, who wanted desperately to be home by Thursday and was sectioned on the ward, started to loiter around the main entrance, watching the main doors. Three other nurses and myself were in the dining room area, where we could see the main entrance. We were keeping an eye on this particular patient, as she had tried to leave the ward before during prior admissions. Things then started to take a turn for the worst. The nurses had to attend to another patient and asked me to keep an eye on this other patient by the main entrance. A couple of the nurses from the other ward were in the dining room area, but didn’t have a completely clear view of the main entrance and ofcourse, they had their own patients to watch. After successfully deterring the patient from attempting to leave the ward on a number of occasions, it finally happened. A visitor was leaving the ward and I saw this patient turn towards the main doors. I went after her and called out her name as she got to the doors. She slipped through the doors after the visitor and suddenly my heart started pounding. She had made it off the ward. Adrenaline kicked in and I just ran, calling after her. She ran past the visitor and towards the stairs. I burst out of the ward doors and chased after her, running down the stairs. I could hear two nurses running behind me, I was pleased to hear I had backup with me. On the second flight of stairs I caught up with the young female patient and grabbed her arm, but she shook free. Not wanting to cause her to fall down the stairs I decided not to grab her again until we were off the stairs. I jumped down the last five steps and chased after the patient. Ten feet away were the first set of automatic doors. This slowed the patient down and gave me chance to close the distance. As she passed through the first set of double doors I grabbed her around the waist with both my arms. She was powerful and obviously determined to escape, but I was able to prevent her from going through the external set of automatic doors. By this time the two other nurses had caught up with us and were restraining the patient.

I was relieved for the support and backed off as the two nurses took over. I stayed behind the patient, in place and ready to assist if she broke free. The hospital manager was also there to assist, if required. We took her to the lift and then back up to the ward, where she was given some sedatives and put on close observations. I have worked with psychiatric patients a lot, both before and during my nurse training, but I have never had one try to escape on my shift before. I certainly reflected on this incident in my professional reflective journal. I learnt a lot from this incident, the first being, why didn’t I activate my personal alarm before chasing after the patient? What would have happened if I hadn’t been seen chasing after the patient by the two other nurses? Why didn’t I atleast call out for assistance when I engaged on the chase? Even though I called out the patient’s name, without calling for assistance I could have ended up persuing her on my own with no back up support once I had caught her.

After that we had more excitement on the ward as a new patient was admitted. This male patient had spent the last month abroad and was being admitted following a ‘manic’ episode, which had resulted in him being detained by the police where he was then detained under section 3 of the mental health act. When he was brought onto the ward he was extremely manic and under the influence of alcohol. After an assessment with the on-call psychiatrist he then came back onto the ward area. He was verbally abusive, demanding that he speak to his private psychiatrist or he would sue the hospital, demanding that he phone his solicitor, accountant and anyone else he could think of. At times he was that worked up that his speech was incomprehensible. It was such an interesting case that I stayed on after 5pm, although only by ten minutes, but enough time for me to see the nurses calm the patient down slightly and talk him into taking some of his medication. It was certainly a very interesting and educational shift. However, it also reminds you just how much suffering people can experience who have psychiatric or psychological illnesses or disorders. It is such an unfortunate situation for anyone to find themselves in. Then you try to compare medicine non-compliance for a patient with insulin dependence diabetes against a patient who has schizophrenia. It makes you wonder if some non-compliance management strategies used in psychiatry could be successfully adapted and transferred to manage non-compliance in some medical patients.

Student Nurse Blog Year 3 - Week 19

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