Create Foundations First!

It has been a while again since my last blog! I have been very busy with work, gym and trying to tame a new ex racehorse I have obtained!! Most people who know me know I like to keep myself busy! The last time I wrote my blog I had just started my job at Derby Hospitals NHS FT, moving onto elderly medicine. I am now talking to you on my second to last day oN my rotation and I am now going to talk a little bit out my progress and some of the things I have come to realise on my journey!

From past experience working at the Queen Elizabeth hospital, on a medicine ward. I had identified I needed to continue to develop my ward prioritisation and management skills to be successful on my new rotation of elderly medicine. It was difficult coming to Derby because having only experienced physiotherapy in Birmingham there were different policies and procedures to follow. For example in the morning we have a daily board round to discuss patients with the MDT whereas in Birmingham we had a weekly MDT meeting. I have found the board round has worked quite well because it creates an opportunity to discuss problems and identify patients earlier who are becoming medically fit for discharge. Although I am from Derbyshire, I never realised how huge the county is, so figuring out where patients are located was initially a challenge however this was made easier with the fantastic nurses completing  inpatient rehab forms for us after completing goals (what a luxury!).

So I wanted to talk about some of the things I have learnt along the journey which I hope will be useful to all physiotherapists not just students and graduates. My opinions are not gold standard they are just an opinion so please formulate your own clinical reasoning.

Prioritisation 

This is a skill I have really had to refine. In day to day life I am a very organised person however  my problem in terms of the ward management were I wanted everyone to have daily physiotherapy sessions. But unfortunately i realised this is not always possible due to the complex busy caseload . I Initially I found it difficult to lead the caseload partly because there was more than one physio  on the ward, my supervisor (which is great for learning). So we tried not to tread on each others toes. Further more I also lacked confidence and experience to challenge some of the views of the MDT with regards to discharge planning which hindered my initial development. With the complexity of some of the cases on the ward it took me a bit of time to demonstrate my full prioritisation skills, but over the last 4 months I have progressed to the point of feeling confident that I could transfer my ward management skills to any acute ward based setting. 

 

So below are some of the things I have learnt along the way:

  • Everyone has different methods for prioritising, but the way I have gone about it in a simplistic view due to the many factors which interplay : Respiratory patients not managing their own secretions, new patients who need a full assessment (prioritising patients who are requiring chest physio and those coming up to be medically fit for discharge), patients who are medically fit for discharge without a plan for discharge, patients at risk of deterioration if they are not seen and finally patients who are being monitored on the ward.
  • Prioritise patients who require assistance of  2 to ensure staffing can match the need in the afternoon.
  • Unfortunately when you want to see patients on the ward most of the time they do not always fit in your specific time slot so you have to be flexible with your management. 
  • Don’t be afraid to delegate you are not alone (hopefully). If you work with a physio assistant is there any patients that they could see for you on their own? Is there any admin needs they could complete for you?
  • And finally relax! You can only do what you can do! You are not superman or woman! (although I try to be),,, you are better to complete assessments thoroughly to create a plan rather than coming out of your assessment thinking what information have I gained from that?

Multidisciplinary Team Working

I have been very fortunate on my ward to work with a fantastic MDT who are very pro therapy to facilitate discharge. Coming onto my ward I initially felt the high bed pressures looming! However, this has encouraged me to devise a plan earlier and ensure I was continuously liaising with members of the MDT to create a discharge plan with the aim of preventing readmission. Working with the Frail elderly you will be presented with some complex cases such as patients at risk of falls, cognitive impairment, patients refusing social services or patients who do not meet social services funding, patients with complex commodities and finally patients with varying conditions.

Sometimes you are presented with some very emotive cases and you can feel as though you are playing with peoples lives. From our point of view we can only recommend what a patient should do to maintain there safety. However, if patient has capacity to accept risk or go home ignoring recommendations then that is their choice to make. We should be facilitators not dictators. I sometimes felt quite stressed with some of the situations I was faced with, with some patients being border line whether they are safe at home or not. However that stress is important because it ensures I am conscious of my decisions to strive for the best care for each individual patient. I think if you don’t have some form of internal stress and are going through the motions in your job this may come back and bite you in some point of your career. For patients we should be assessing them holistically and taking a 24 hour approach to theIR discharge…. Are they able to manage hygiene needs between care calls? Are they able to sit between care calls? Do they have any pressure sores? Do they have a cognitive impairment? Are they safe with there mobility? Are they able to complete bed/chair and toilet transfers? and finally Are they any safety hazards or risks for the patient returning home? These complex discharges cannot be completed seamlessly without an MDT approach so get to know your team and start communicating!

Preceptorship

It wasn’t long ago I was talking about starting my preceptorship! I am pleased to say I have now completed it to 6 months and have gathered evidence throughout my rotation to support my objectives, The objectives I was set were:

Working with patients and groups: I demonstrated this through joint sessions with my supervisor and a self evaluation form,

Working with colleagues and other agencies: I demonstrated this through a complex case study with a reflective piece and copies of some of my record keeping demonstrating liaison with different members of the team.

Written Communication: I demonstrated this by taking 5 sets of notes and analysing what was good and bad about them.

Using Local and clinical policies relating to working practice: I completed a reflection on infection control and completed a notes audit for the team.

Aside from my preceptorship I was set rotation objectives which interlinked with the programme. It might be a bit geeky but lets face it not many people spend time to document their experiences like me anyway ,but, the preceptorship process really did hone my reflective skills which will support a career long commitment to reflection and CPD in future practice. 

I have loved my time working with the elderly medicine team and I have had ample opportunities to develop my clinical reasoning, prioritisation and overall ward management. I now feel confident that I can transfer these skills to another acute ward based setting, to deliver a quality service to my patients. It was fed back to me that I sometimes set my expectations too high of myself. This has been the case for many years but it is the driving force which allows me to strive for the best. On the other hand, I realise that it is important to get the foundations right first to  develop a solid base for development and that there is no need to rush, at the end of the day I am only still in my 1st year of graduating :-S!

 

Action Plan and the Future.

So in the pipe line for me…. next Tuesday I will be starting on my respiratory rotation (eek), I have completed the 2 week intensive training given by the trust so it is now up to me to get my head in the books to get my head back into respiratory management! Aside from this you may be aware from my last post I wanted to find a mentor to help refine my leadership skills…. well I am pleased to say I have found one and not just anyone. Sarah Bazin OBE has happily agreed to help me and we will be meeting next week :-). Sarah is the current chair of the European Region of the World Confederation for Physical Therapy (ER-WCPT) so I am honored to be working with her over the coming months!

My latest action plan…

  • Revisiting my respiratory assessments
  • Thinking of objectives for my respiratory rotation
  • Creating a 5-10 year plan with the help of Sarah as appropriate

I think that will be enough to keep me going for now. Thank you for taking an interest in my blog! Please feel free to leave a comment or Tweet me @LCphysio . 

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One thought on “Create Foundations First!

  1. Great read Lucy. Like yourself I have been fortunate enough to work with the Elderly Medicine team at Derby albeit I was only a second year physio student. One of the major contributing factors to the ward is the MDT who had a great rapport. Daily handover, everyone mucking in together ie physio helping HCA/nurses out by taking patients to the toilet, to nurses cleaning down our rotunda after we used it if we are a bit rushed off our feet. The discharge process was mainly very smooth as everyone knows their role and the d/c facilitator rarely had to badger us.

    It was at times a sad placement with respect to the fact that some of the patients had no family and we’re residing in residential home, others were in severe stages of dementia whilst others had resigned themselves to dying. However it was also one of my most enjoyable placements as it was a great team to work for, and I learned so much about patient caseload, discharge planning and looking at the bigger picture after mobility.

    Good luck with your respiratory rotation!

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