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Supernumerary? I beg to differ!

28 March 2014

When you start your first placement, mentors and lecturers stress over and over again that you are not to be counted in the staff numbers on your placement and that you must not be sucked in to becoming an extra body on days of staff shortage. You should of course help out and patient safety always overrides your learning but you should never be denied a learning opportunity just because the ward is busy and cannot do without your help.

Simple, right?

Not so. Most nursing students want to be helpful. We want to be liked and seen as hard working. Wards are almost always chronically understaffed. And who could say No when a health care assistant asks you to wash a few patients in the morning whilst your mentor is writing notes or preparing paperwork for a discharge. After all, you would only be sitting next to your mentor when you could be on the ward helping out with what most people think of as 'real nursing work'. And so, all too often, students say yes to such requests. Or we offer to help out before we are asked, thus creating a rod for our own backs. And we miss out on learning how to do discharge paperwork. But surely a patient is more important than paperwork?

Yesterday I was called to A&E by a trauma nurse who wanted to show me a particular injury on a patient who had just come in. He would be transferred to our ward after assessment so the nurse thought it would be good for me to see the entire patient journey from A&E admission to surgery to ward and eventual discharge. I left the ward to go to A&E and see the patient. When I returned 15 minutes later, I mentioned to one of the HCAs that I was hoping to go to theatre later on to see the patient's wounds being sutured and then bring him back to the ward. Her response: "Not today, you won't. We are too busy as we are an HCA short." I laughed it off and said in a jokey tone of voice: "I shall be reporting this to the university as you know we are not supposed to be denied learning opportunities just because the ward is under-staffed." The HCA laughed and encouraged me to do so in the hope it would demonstrate once again how understaffed the ward was. I was taken aback and did not know what to say to that. What should I do? Should I go anyway, knowing she said they really could not miss my pair of hands? I knew that leaving would mean a patient might have to wait a long time before having their soiled sheets changed. Or they might not get their afternoon cup of tea. Was my learning opportunity worth that? Of course you should help the patient if this is a one-off. But what if this pressure is structural?

How can they ask a nursing student, who gets compassion drilled in to her from day one, to be selfish and say: sorry but I need to put my learning needs first, I am here to train to be a nurse, not to be used as an HCA? Not every student is lucky enough to work closely with their mentor every hour of their placement and thus being protected somewhat from this pressure. I mentioned the comment to my mentor later on and she was not happy about it, saying she would rather send a student off to study in the hospital library than have them used as an extra body to make up for staffing shortages. So I felt better about it, thinking my mentor would fight my battle for me and tell the HCAs not to pressure me in to missing out on learning opportunities. Because I am simply not strong enough to do it. I simply cannot watch a patient in a soiled bed, knowing I could help if only I did not insist on learning how to write up discharge notes. On the other hand, I know that if I do that every time, I will end my degree as an excellent HCA but a rubbish nurse.

In the end, the patient did not go to surgery as it was too late in the day. He arrived on the ward straight from A&E and would have surgery the next day, when I was not on shift. I felt relieved because it meant I did not have to make myself unpopular with the HCAs by leaving the ward. However, it still made me feel uneasy. This issue has bothered me from day 1 on my first placement. How can we guarantee nursing students get a full learning opportunity when the pressure on them to help out on the ward is so great that it interferes with their learning? Especially at a time when more and more experienced nurses are leaving the profession, leaving relatively newly qualified nurses to fill the gaps, how can we ensure these newly qualified nurses have had enough suitable placement experience? I don't know the answer to this and I would love to hear from other students how they handle this pressure without feeling the burden of guilt when they walk past a soiled patient in order to learn to write discharge notes…

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This blog first appeared, in a slightly different version, as a guest blog on Britain's Nurses.
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How the hell do you revise pathophysiology with ADHD?

01 March 2014

I am a clever girl. I am also unable to wrap my head around the concept of revision. I don't know if this is me being weird or if this is an ADHD-related issue or what but I am seriously struggling.I know other people are struggling too and I am not trying to make this sound like I am worse off than they are. Just thought I should get that in first.

From when I was a kid, my brain analyses what I am trying to do and says: OK, I get it, you can do something else now. This does not mean I REMEMBER the thing I have just read but my brain says: I read that and understood it, let's move on. And from that moment on, I am unable to concentrate on that topic because my brain is bored, even though my memory has not yet absorbed the info and committed it to memory, ready for regurgitation in the exam. Every time I try to revise the topic, my brain goes: "Yeah yeah, you know this already, do something else, something I don't know yet." It is as if my brain says: I understand the concept, so I don't need to know the content.

Example: in this exam I will probably be asked to compare and contrast Diabetic Keto Acidosis (DKA) and Hyperosmolar Hyperglycaemic State (HHS). I have read the differences and similarities. I understand why things happen when I read my book, I nod and think: yep, seems good. I close my book and try to answer the exam question and I am utterly lost. I can not list signs and symptoms, nothing but the very very basics. So I open my books again, read the chapter again and my brain goes: "Why are you reading this again, you just read this and you already understand it. I AM BOOOOOOOOORRRRREEEEEEED."

I have read all the exam topics. I understand all of them. But hardly remember any of it.

In true ADHD-style, I try to trick my brain in to thinking I am doing something new. I do this by trying to find a new way of revision. That way, my brain will pay attention for a bit because it is a new way of absorbing information. So I started the revision for my pathophysiology exam by printing off all the lecture slides and all my lectures notes. For a few days I read and read and took notes. Then I could feel my brain going: "Lalalalaalaaaa.....I'm not listening anymore." I tried for a couple more days but nothing went in.

So I thought I might try oral revision: no writing, just talking with fellow students about the material. That worked for a couple of days.

Then I thought: how about group-mindmapping? I got a few students interested, we went into a classroom and wrote all over the whiteboards, made mind maps, lectured each other on things we were sure about. It worked really well. So well that different students showed up each time.

After 4 sessions, my brain said: "Lalaalaalaaa......Why are you doing this? You know all this. Move on!"

So this morning, I decided I would answer questions from previous exams and compare my answers with answers from a few fellow students. We arrived in the library, set a timer for 10 minutes and picked a random question:

Compare and contrast signs and symptoms of chronic bronchitis and emphysema.

I KNOW the answer to this. Or at least, I UNDERSTAND the answer to this. Unfortunately, when we all compared our answers, my answer was vague, repetitive and quite shallow. I did not mention hypercapnia, hypoxia, digital clubbing, cor pulmonale...nothing. My answer wasn't wrong. It just wasn't enough. I could not reason it through. I could not remember. These 2 diseases are quite similar and quite often people have signs & symptoms of both. So how the heck can I differentiate between the two if I don't understand the pathophysiology behind each of the symptoms. Why is someone with Chronic Bronchitis more hypercapnic than someone with Emphysema? They are both struggling for breath so why the different outcomes?

Part of it is probably nerves. If I had 20 minutes for each question, here is how I wold be able to answer the questions:

1) Think of the disease
2) What is the first thing that happens? Which process goes wrong, which enzyme causes that, etc.
3) What does this lead to (i.e. what sign or symptom does this cause?) And WHY?
4) What happens after that & what signs/symptom does THAT cause? And WHY?
5) And so on.... And WHY?

That way, I will 'walk through' the illness and logically come up with many of the answers required.

Unfortunately I have only 10 minutes per question and so what I need to be able to do is:

1) Give a list of signs and symptoms, the order does not matter as long as you list enough of them to pass! Also, this is not a patho-question so just list signs and symptoms and you do not need to explain why things happen and why this symptom occurs. GO!

And I just can't do that. I just do not understand how to do that.

All of this obviously on top of the exam stress everyone feels and the ADHD-related inability to plan or remain concentrated for longer than 30 seconds.

This post may sound really self-indulgent and navel-gazing. Like I am saying: I have it worse than you, feel more sorry for me. It is not meant like that. I am just at the end of my tether with this. Because there are only so many different methods of revision I can come up with. And for this exam alone, I have already tried 5. What if I can not invent any more for the next exam. Or, God forbid, the re-sit of this one?


PS: I only started writing this blog post because I was looking online for tips and hints on revising when having ADHD. It is now an hour later, I have not revised yet and also not actually looked for any of those tips....I got distracted. Ugh.
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