Learning Opportunities

Hey guys

Sorry i just wanted to finish my blogs off for the year so im posting this early. Through out the year, there have been pracs which i look back on now and just cant help but think that i didnt make the most of them when i was there. I think at different points in the year i lacked some motivation or was just feeling burnt out and didnt extend myself as much as i could have. Sometimes this was the case of not having the opportunities available and quite frankly not asking for them on my behalf either.

I am currently on my rural prac at the moment and i absolutley love it. Every day the effort is made to teach us something and anything i want to learn whilst i am there i can do i just have to ask. The orthopaedic senior will give us tutorials whenever we ask on any joint, has taught us heaps of mulligans and mckenzie techniques and stuff, plus im on inpatients but i prefer outpatients so ive been allowed to spend extra time in OP if i ask, if i want to do more community trips im allowed. Basically i just find it so much more relaxed, before i was worried i would look like a pain if i asked to try different things, now i realized instead of just waiting and hoping the learning opportunities will be presented to you, that sometimes you have to go out and seek them yourself. I have found that the pracs that i have made the effort to really extend myself, i have enjoyed much more as i have not been getting bored from just doing the same thing, or feeling im not learning that much. Which at times has left me quite frustrated.

I think this is the perfect time to try and learn other things were not taught at uni and expand our knowledge as much as we can. It is much easier to give new things a go when there are other people around to give you feedback and tell you how to improve what you are doing. So I guess if anyone has a proper prac left rather than SDP, try and make the most of it and see as many different things as you can and just take responsibility for your own learning, because i think you get a far better feeling of accomplishment for it.

Good luck with the rest of your placements

Documentation

During one of earlier my placements I came under scrutiny for my documentation in the integrated notes. I was a little confused as I was still using the SOAPIER format but I was just missing out the A and the P, as this tended to be just a rewritten list of the above assessment. The other physio’s had written even briefer entries tending to write only the most essential things and often taking up less than 4 lines ( I was taking up about ¾ of a page). I discussed this with the supervisors and agreed to write out full SOAPIERs for every patient to further my understanding of the patients problems, my entries were now well over a page.

During subsequent placements I managed to shorten the length to about ¾ for a new patient and about half a page for continual patients. I dropped the A and P and focussed on the other areas.

I was still writing more than most physios and it made me wonder if I was writing too much. I talked to a couple of physio’s about this and they had differing opinions. Some would say that it would always be better to write too much than not enough, while others would say that you should write the bare essentials as doctors, nurses etc often get annoyed at having such thick files for patients integrated notes.

This made me think and reflect on not only my own notes but what the purpose of writing integrated notes was. Surely we need to describe our assessment we have performed and the treatment we have carried out not only for legal reasons but to enable other health professionals to gain a greater understanding of just exactly what we are doing and have done with the patient. Giving a 4 line entry not only gives false impressions as to what we are doing with the patients but undermines our role as it portrays a simplistic and seemingly unnecessary treatment. This situation made me realise that we need to be thorough with our documentation to ensure our continued role in the health profession as well as to ensure the safety of the patient.

The anxious patient

Hey guys! My apologies, I owe you multiple blogs…

On my current rural practical, I spend half of every day in musculoskeletal outpatients. Last week I had a patient called Lucy* who had been referred for neck pain. Upon getting Lucy from the waiting room it was instantly clear to me that she was very anxious++.

On the short walk from the waiting room to the treatment cubicle Lucy made several comments, including “it’s like going to the dentist”, and she appeared overwhelmed by the size of the physiotherapy department. During subjective questioning it became clear that she had some psychosocial issues (she was being treated for depression), and she became very apologetic if she could not recall the answer to certain questions. When it came to assessing PAIVM’s during the objective assessment, Lucy became claustrophobic from lying in prone with her face in the hole. As a result she had increased tension throughout her cervical and shoulder girdle musculature and this made it very difficult to gain any information from PAIVM’s.

It was at this point I began to recall the communications units we did with Penny, waaayyyy back in second year. We discussed a similar scenario in which a patient presented to physiotherapy extremely anxious, either due to a preconceived notion of what physiotherapy was about, or because of a bad experience with physiotherapy previously. Penny made several points when discussing this scenario 1) that we should spend more time building rapport with such patients, 2) that we should go out of our way to make sure the patient is comfortable, and 3) that we should be more gentle in our assessment and treatment than we might otherwise be to ensure the patients return. Unfortunately I hadn’t really followed any of these principles! However after the flashback I changed my approach. I positioned the patient sitting in a chair, leaning forward and resting her head and arms on pillows placed on top of the plinth. This ensured that she was more comfortable. As treatment, I simply went for a hot pack for 10 minutes over the neck followed by a gentle massage of tight structures. The patient found this quite pleasant and her anxiousness decreased as a result.

In the future if I come across a patient that is particularly anxious I will follow the principles that were discussed in our communications units. This will help to ensure that I gain the patients trust and leave them with a better impression of physiotherapy than they may have had previously. Also, it is important to note that it is never too late to change things if we find that they are not working mid-assessment/treatment.

Supervision & Independence

My neuro placement was quite an interesting one. The hospital I attended did not have a specific neuro ward and instead was to be move and see neuro patients all around hospital. In addition to this I didn’t have a set supervisor, instead I was to report to the physio on the ward I was currently treating a patient on.

Initially it was quite disorientating, as I was constantly changing wards and supervisors. But eventually as with most placements you become accustomed to the routine and the structure. Due to the fact that I was on many wards and had many different supervisors it was often unfeasible to have a supervisor present with every patient. Although it was made clear that if I needed help or was unsure of something with a patient I was to come and get the supervisor on that ward, it was often hard to gain feedback on how I progressing on my handle skills and alternate treatment methods that I could employ with different patients.

Although this situation gave me independence and lead me to develop my organisational skills it left me a little unfulfilled as I felt I was learning as much as I could. I spoke to my curtin tutor about this and she suggested that I try and get at least one supervisor to see me with a patient at least once a day. I tried this but realised that it was unrealistic to get seen everyday, so I managed to get seen a couple of times a week by a supervisor. This initially worked well as I picked up a few incidental things that helped me to deliver a better treatment and assessment, but I still felt that it wasn’t enough. So I asked specific supervisors if I could observe them with some of their patients, and arranged times that I could have a chat to supervisors about patients regarding possible alternative treatment methods. This turned out quite well, enabling me to get a few different perspectives on treating similar patients.

Reflecting back on this placement I think I got the best of both worlds, by developing my independence (and finally feeling like a real physio) as well as still having that support there to be accessed (with some organisation on my part-which was also a learning experience) if needed. I think often we are “spoon fed” a little bit as a physio students by being told how to do everything with step by step instructions that often leave little room for creativity which can stifle us in the long run. With that in mind I think it is important to develop a little bit of independence while still keeping the training wheels on.

Rest Time

Hi guys

Where i am currently on prac, there is a 3 hour rest period for patients, which runs between 12&3. We get lunch during 12-1, however when we come back from lunch all the lights are still switched off on the wards. It is impossible however to get through a very full caseload if we abide this time and therefore the rest time is only intended as no visitors are allowed. The other day i went to go and treat a patient, and a nurse was quite aggressive with me she told me i couldnt see any patients till 3 oclock and that it was rest time.

I tried explaining to her that to get through a full caseload we cannot just not see people for 2 hrs, however she kept being stern with me and so i went and sat down for about an hour and a half and tried to use my time effectively doing paper work etc.

I ended up finishing half an hour late that day as i didnt see any one during that 2 hours. The next day i told my supervisor about the situation as i was quite angry i finished late, and i was quite sure we were allowed to see patients during rest time. She had been told the same thing by a fellow nurse a week earlier.

The physiotherapy department was very upset with this and sent one of the seniors up, to speak with the nursing coordinator, who was very angry at the staff that had told us this, another message was sent out to all nursing staff that we were allowed to see people in rest time, and i was told if anyone else tried to tell me that whilst i was there to come and tell them immediatley.

This situation again has just shown to seek out help if there is a situation you cant deal with. I didnt want to start an argument with the nurse and being a student didnt feel like i had much authority and didnt want to get offside with the nurse.

Mental Health

Hey guys

hope all is well. This part week i have been treating an elderly gentleman, who was in hospital for an amputated toe, he was originally discharged, however readmitted himself to hospital one day later. Over this time he has deteriorated significantly, mainly due to depression and severe lack of motivation, he is not eating and refusing to move out of the bed, previously i could get him to perform bed exercises and at least stand. Due to this increasing uncompliance with all staff members he has developed pressure sores on his heel etc. The other day i went to see him and he would not even perform bed exercises.

I had spoken to my supervisor and expressed my concern that if he didnt get up soon he wouldnt be bale to walk in the next few days. Due to his increasing non compliance she suggested i ask him if he wanted to end up in a nursing home, cause that was were he was headed as a last resort to try and get him up.

So I said this to him, even though i never felt particularly comfortable using this as a threat, this also had no effect on the situation. I know how important it was for me to try anything i could to get him up for his own welfare, however i dont think i will be using a technique like that again i felt absolutley horrible saying it, and i dont think it helped the patients current mental state either. I gave up for this treatment session and instead asked for mental health to review him. I will wait until this has been done as in the meantime my input is useless, i dont feel that anymore pushing will do anygood.

Displaying Presence

My next session with Tom* on my orthopaedic inpatient placement I was able to start mobilizing Tom. I saw Tom with my Curtin supervisor for this session. Because of Tom’s complicated and prolonged hospital stay I decided to take quite a cautious approach by explaining to Tom that if at any time he felt dizziness, nauseous or anything else abnormal to let me know immediately. I also explained to Tom that we would take it slow and we go to sitting over the edge of bed, stay there for a little while and then if things were okay there than we would try a stand with the pulpit frame. Tom agreed to all this. We moved to sitting over the edge of the bed and I continued to question Tom regarding dizziness etc and he said he was fine. I decided to try a stand with the pulpit frame, Tom was quite keen and seemed to be a little frustrated at how slow and cautious I was taking things. I explained to Tom how I wanted him to stand up using the pulpit frame by first pushing on the bed with both hands and then once half way up to bring his hands to the pulpit frame and take the weight through his elbows on the pulpit frame.

Tom then stood up but put his hands on pulpit frame too early, he still managed to stand but was not as safely as I had liked so I told him that I wanted him to sit down and try again. Tom was visibly frustrated but my supervisor and I tried to explain to him that it was important that he learn to transfer safely. I then re-explained to Tom how I wanted him to stand safely, and on the second attempt Tom stood safely.

When receiving feedback from my Curtin supervisor she commented that if this session was my final assessment she may be inclined to fail me on a safety issue. This obviously caused me to reflect on what I could have done to prevent this potential safety issue. I first thought about if I had explained how I wanted Tom to stand...yes I explained but I may have not enforced my presence and ‘authority’ enough. Then I reflected on why I didn’t do that and with some discussion from my clinical supervisor I came to the conclusion that it was the fact that I felt inadequate being so forceful when I was still a student. Reflecting on this made me realise that it is of the utmost importance to display confidence in what we are doing and display a sound presence to patients not only to ‘sell’ physio to our patients but to ensure safety at all times. During my next sessions with Tom and other patients I made sure that I displayed a greater presence and confidence in what I was doing.
*Fictitious names used