Advocacy

Advocacy is one of the most important and under utilised components of a Nurses job. It sits at the very core of our being, the reason behind every action, and heart behind every conversation with a Doctor. Recently, whilst caring for a patient, I didn’t exercise my right to advocate for them, and as such they have continued to be mis-managed. For confidentiality reasons I will not disclose particulars of the patient, but will instead refer to them as Jeff. I have come up with a nemonic of ABCDE to remind me of the components of Advocacy for the future, and I hope they will help you too.

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Always

As some of you are aware I am both an Enrolled Nurse, and a student Registered Nurse. I am also on my last placement before graduating at the end of the year. I felt that because Jeff was a patient of mine, whilst under supervision, as a student I couldn’t or shouldn’t raise my concerns and subsequently Advocate for them. I was wrong. As Nurses we should always feel empowered to Advocate for our patients. It doesn’t matter if you are a LPN, EEN, AIN, GRN, RN, CN, or NUM you should feel comfortable to stop what is happening and Advocate for your patient. I have been beating myself up since the event, and cannot seem to console myself regarding my inaction. Jeff continues to be, in my opinion, mismanaged because I, and others, feel that we cannot raise our voices and say STOP, this isn’t in the best interest for the patient. STOP, we need a different course of action. STOP, we are not caring for and treating this patient, we are treating our own conveniences. I wish I had spoken up, but now I know what a difference it could have made, and how lousy it feels when I don’t, I will never step down from Advocacy again and I will encourage others to do the same.

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Back Up

When Advocating for a patient we should remember we aren’t just individual Nurses, we are part of a team, and we are stronger together. That wasn’t supposed to sound like a chant for a Union, but there you go. If we don’t feel strong enough to confront a Doctor directly, enlist help from other Nurses in the team, bring in the Supervisor, the Shift Coordinator, the Clinical Educator, the Clinical Facilitator, or even the Nurse Unit Manager. Together you can approach the Doctor and Advocate appropriately, it will look less like an idea from a solo Nurse and more like a considered idea, and it is good to know that you are justified in your Advocacy when you have the assistance of another. This won’t come across as “Ganging Up” if done correctly, and could be the component you need to successfully Advocate for your patient.

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Considerate

As Nurses we pull some pretty long and random hours, with things like Late-Early shift, overtime, Double Shifts, and a myriad of other whacky ways the roster seems to wind up. Our job is physically demanding by being on our feet all day, lifting and rolling patients, performing care, and everything else we do in a shift. Our job is also emotionally and mentally draining with supporting the patients and their families, dosage calculations, evaluating observations, constantly assessing a patient, and somewhere in all of that is Advocacy. Now, we all know what we do is demanding and exhausting, we justify the extra coffee, the second bar of chocolate, or ignoring the phone on breaks because of it. We flay ourselves over jobs missed, or errors in judgement, and we feel terrible when things are late. Now, our Doctors may not be there for the hands on cares, the lifting and rolling, the supporting the patient during mobility, but they are carrying the burden. The Doctors are trying to manage a massive patient load, the medications, the investigations, the outcomes, the families, and the demands we as Nurses put on them. The Doctors are under the pump all the time. They can’t ignore the phone, their breaks are constantly cut short, they are the ones that get to explain to the patient and their family about a poor prognosis. They have a huge burden to carry. When we advocate for our patients we need to be Considerate and keep in mind these burdens. Don’t Advocate by telling them they are wrong and should be doing it a different way, or calling into question their education. Come along side of the Doctors and show them what you are seeing and suggest the alternative course of action.

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Don’t forget the Patient

We shouldn’t forget that the reason we advocate is for the best outcome for the patient, as such we shouldn’t forget to include them in the decision making process. It may be entirely necessary, and entirely justified to discuss your concerns with the patient prior to stepping up in front of the Doctor. Some patients, despite the best intentions you may have won’t want to take differing actions to what the Doctor has ordered. This is why it is important to discuss your concerns with the patient, or if the patient is unable to then a discussion with the next of kin may be appropriate. This seems simple, but can be just as difficult, if not more difficult to achieve. Discussing with a patient that the care that has been prescribed isn’t the best, and a different action would be better, can be seen as conniving, sinister, arrogant, or just plain rude. A polite tongue and respective tone when discussing this matter will need to be adopted, and under no circumstances should the Nurse belittle or bad mouth the Doctor, or professional prescribing the care. We are all a team, we need the Doctors just as much as we need them, nobody wants to be seen as “That Nurse” and as such we shouldn’t behave that way.

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Evidence

Whilst we should advocate for our patients, always, we need to make sure we have the evidence required to back up our claims. This can be something as simple of observations, blood work, an x-ray, comment made by family or friends of the patient, or statements made by the patient themselves. We may also have written evidence from Journals, textbooks, Research Articles, or recently attended workshops or conferences. It may be something as simple as showing the doing guide from MIMS or the product information leaflet enclosed with the medication. We as Nurses need to be prepared when confronting Doctors in relation to our patients, it may not be enough for us to simply say “I am not happy, we need to do something differently”. Being educated, well read, up to date, best practice using badasses we are we need to show the Doctors that we know what we are talking about, and that we need to be listened to.

These five components; Always, Back Up, Considerate, Don’t forget the Patient, and Evidence or ADCDE, will help you remember what needs to be considered when Advocating for your patient. Don’t end up where I did with Jeff. Don’t be afraid to stand up and be heard. Don’t think that you are just a Nurse. You are the patient Advocate, exercise the right, but do it properly.

Maintain the Rage

Luke Sondergeld

12 Hour Shifts

I have started my placement in the Intensive Care Unit (ICU) of one of the hospitals in my region. Like most ICUs they run on 12 hour shifts, specifically for the one I am placed at 0700 till 1930 and 1900 till 0700. On the surface this seems great, over 3 weeks you work 10 days and are still counted and paid as Full Time, you have 11 days off over the same period, there is no such thing as a late-early, and the likelihood of being asked to stay back is greatly diminished. Though all of these things are true, and I will expand on some in a moment, there have been some interesting issues develop along the way.

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The Roster

I have to admit, the idea of 12 hours shifts, 11 days off in 21, and never having to work a God for sake Late-Early again, is awfully appetising. I adore the fact that the days you work, in which you seldom get anything done anyway, are just a little longer. I do enjoy the possibility that you are handing over to the person you received handover from. On the surface it seems like the dream, but there is a catch. So far I have been doing nothing but day shifts, which involves getting ups at 0530 to get ready and leave the hour by 0630 to be at work ready to go by 0700. The day then proceeds thill 1930 when I depart, walk to my car and drive home, arriving somewhere between 1945 and 2000. So far in this day I have not seen my children or wife awake, on arrival only my Eldest and Wife are still awake. No biggie, spend some time with them, wind down then off to bed, to get up at 0530 and do it all again. As you can see, there isn’t a lot of family time going on. There is  a lot of just surviving. Working, eating, sleeping, working. When I first arrived to ICU the Facilitator made a remark about working 12 hours shifts and how you shouldn’t expect to get anything else done on those days as you are just doing what you need to do to get to the next shift. I scoffed when she first said it. Now that I am living through it, she isn’t far from the truth. You wouldn’t be able to engage in any drawn out, meaningful activity. Normally I eat my dinner with my wife, we talk about our respective days, she returns to her school work, I read for a while, then sleeping for the next day. It took me by surprise. So though on the surface the roster seems really good, just keep in mind, you are almost useless for 10 days out of 21.

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Self Care

The need for self care is incredibly important while undertaking 12 hour shifts. You need to make sure you are adequately fed, a mistake I made on the first day, just catering for lunch and that was it, didn’t make that mistake again. Staying adequately hydrated, which I know as Nurses we are notoriously bad at but we need to make an effort to do it. Getting enough sleep, and I mean good sleep not naps on the couch or two or three small naps, I mean a good solid 8 hours, which when you do the math leaves you with 4 hours for EVERYTHING that isn’t Work and Sleep. Supporting the home front, for those of us that aren’t single and have a partner and maybe children, you need to make sure that they feel adequately loved and supported. It is all too easy for us to say that we are tired, and worked a long day, and were on our feet all day, but your partner has also worked all day, cooked, cleaned, organised the finances, or performed ALL the other homely duties that aren’t getting done because of the 12 hour shifts. You should also engage in a ‘Me Activity’ on your days off. This could be hiking, swimming, boating, painting, or stacking rocks, whatever your chosen ‘Me Activity’ is make sure you take the time to engage in it, it is all too easy to just work to live and live to work.

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The Shift

Talking about working 12 hour shifts could not be done without actually talking about, the shift. I can only talk on the Day shift presently but as I engage in Nights I will be sure to add my thoughts. But, the shift, putting aside the obvious thing which is it is 4 hours longer then a normal shift, is divided rather nicely into roughly 3 hour blocks. Each shift you have a single 20 minute break and two 30 minute breaks. They are usually taken around 1000 for the 20 minute, 1300 and 1700 for the 30 minutes. This gives you Morning Tea, Lunch, and if you wish an Early dinner, I tend to simply enjoy a coffee and the extended break time for my 1700 break. This break pattern helps divide up the day and ensure you aren’t too intently involved on the floor for too long without stepping aside and breathing for a moment. It allows for a little bit of the aforementioned Self Care with regard to diet and hydration, it also allows for a brief period of contact with loved ones to make sure they are adequately supported, and gives you a moment to switch off from the intensity that is ICU.

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As you can see there is a lot to consider with regard to the 12 hour shift, and Nurses have made entire careers around it. I would love to hear some of the stories from those out there that do live the 12 hours shift day by day and what secrets they would like to share with regard to surviving the shift, self care, and days off.

Maintain the Rage

Luke Sondergeld

Working through it

Anyone who has been following my social media on Facebook or Twitter, and those who have been reading my blog for longer than a week will know I have Depression and Anxiety disorder.  This has meant that I have had a course of ECT, been on a myriad different medications, and see a psychiatrist and psychologist on a regular basis. All of this is done with the hope that I can continue to exist with some sort of sense of “normality”. A part of that is I endeavour to continue to live my life as though my mental illness didn’t exist; I study, I parent, I work, and I try to be there for my friends. Sometimes things don’t always go to plan.

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So on a weekly basis I see my psychiatrist for a review of the week, not too dissimilar to what I do on here actually, identify any risks or significant changes in my mental state, and then come up with a plan for the week ahead. This week we discussed how the medication had been sitting, how much coffee and alcohol I have consumed, how my week had been travelling, what my thoughts had been like, how my motivation was, how my sleep was, and as always any thoughts of self harm or suicide. Most of the medication had been sitting with me quite well, no significant side effects, and all performing as they should. The only exception to this was the newly added Quetiapine. It was added to help with my anxiety attacks, and at this task it was performing adequately, the only side effect was it made me a little dopey and sleepy, but thats ok nothing an extra couple of coffees a day couldn’t fix right? The Doctor wasn’t too amused by the number of coffees I was having in a day. His suggestion was to completely eliminate coffee, well actually all caffeine, and to assist in this he changed when I take the Quetiapine. Instead of three times a day I take one large dose at night, it helps with sleep, stops the daytime nap attacks, and assists with eliminating caffeine. I may not eliminate caffeine completely, but I will cut down to one coffee a day. Small steps.

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The past couple of weeks have been intense on the study front. I have completed 26 quizzes, written 1500 words for a reflection on my mental health placement, and a series of small written tasks that are more time consuming than actually difficult. The workload this semester has been a little more intense than I had anticipated, compared to last semester, and in fact the diploma, this semester has required a lot of work in a surprisingly small period of time. The period of time may have been made smaller due to the fact that I had four weeks of ECT, a period of most of the semester in varying states of depression, and losing large portion of my memory that cover the semester and its content. This hasn’t stopped me from studying full time however. I intend to keep this momentum for the remainder of my Degree, thus finishing at the end of 2019. Not long now.

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The past two weeks have seen me on placement at a Mental Health facility. Though I thoroughly enjoyed my placement, the staff, the opportunity to learn, and the new experiences, there were some interesting situations that arose that may not have been an issue, if it wasn’t for my mental state. John was a consumer who was diagnosed with bipolar affective disorder, and was currently in the depressive phase. John was not an aggressive consumer, nor was he deliberately belligerent, or difficult. John was, typically, a polite consumer who was in the throws of the depressive phase of his condition and didn’t know how to deal with it. With this information at hand the conversation was easier to begin, and it made engaging with John possible. The conversation began with idle small talk about how he was going, what he had been up to and the like.  When he answered about how he was going this opened the conversation up to talking about his feelings, what was making him feel low, was there anything that made him feel joy, was there anything that provided an emotional response other than sadness or depression. By listening to John’s responses, asking open questions, being empathetic to what John said, and engaging with him on a personal level, I was able to draw out more from John, and John was able to see more of himself.  The result of this conversation with John saw the rapport together grow stronger, and the conversation to progress naturally and openly. John began to share his story of life prior to his admission, share on his lost loves, his family, his illness and struggles. It took nearly an hour of general conversation before John began to openly reply without the need to have every piece of information drawn out like blood from stone. He spoke about his illness and how it made him feel, how it skewed his view on things, and how it most likely affected his previous relationships. Personally I was affected by the openness and his story, how his illness has affected him, and how it continues to burden him. As someone who suffers with depression himself I found it both confronting and comforting hearing the story. I found the similarities and the emotions to be difficult to swallow at first, and to be honest it are still a little difficult to process. To think that my trains of thought could continue to develop to one day be admitted to an institution such as the one I was working. To have my thoughts and emotions assessed and probed by someone who was in my situation. That thought still lingers.

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My mental health has not had a more profound effect on anything as it has on my family, and my role as father. Thankfully there hasn’t been a direct action caused by my depression or anxiety that has bought harm or ill will to my children. The effect it has on my children is more closely related to apathy. My mood often places me in the position where I do not want to interact with my children, do necessary chores for the children, or otherwise do the necessary things I need to do as a father. This has weighed heavily on my heart. I feel terrible for not doing what I need to do for my children, but at the same token I have no energy or drive to complete the tasks either. I love my children, I want to be able to say I would do anything for them, and have it be true.

I have not been back to work for several weeks, this has been due to the original mental state, followed by ECT, and most recently I have been on placement. Today marks the first day I will actually be returning to work. I am both apprehensive and excited to be returning to work. Though I have no doubt about my physical ability to do my job, or my professional ability to carry out the tasks my job requires, my anxiety continues to whisper in my ear feeding ideas of inadequacies and shortcomings. The end of the shift will be the only true indicator of how the day will go. I just pray the day goes well.

As with most things surrounding my mental health, my friends have suffered through all this. I have bailed on events, forgotten almost everything that has happened or been said over the past month, and almost actively avoided interacting. Though my friends may not think I have been a lousy friend, it is certainly how I feel. My heart is to spend more time with my friends, give them the time they deserve, be there to support and help out when I can. I hate myself for not being the better friend, which causes my depression to take a dive, which leads me to generally being a worse friend, which leads to the loathing again. Thus the cycle continues.

Though the story above may seem to be now of woe and worry, it is not all doom and gloom. ECT has been a raging success, with my mood improving and suicidality decreasing, the medications have been working with varying degrees of success, my walk with God has helped me keep things real, the time I have spent with friends has been great, and I have managed to find time to spend on my hobby.  Things are still hard, I still have thoughts of being irrelevant or unnecessary, I spend most of my day trying to motivate myself to keep my mood up, I am still failing in more areas than I am succeeding, but I am doing everything I can to,

Maintain The Rage

Luke Sondergeld

First Fruits

This week I had the inordinate pleasure of attending the Badging Ceremony (Pinning for our American brethren) of a group of Nurses I mentored during their time at the University. I also had the honour of being the keynote speaker for the event, which was a new and exciting endeavour I hadn’t yet experienced.

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The night was beautifully set up by some of the students, you know who you are, and was primarily put together by those students. The funding for the event came from the Diploma of Nursing Society, which I created and Chair. The night was MC’d by a student with enough charisma to bring the house down, Charlie you did an excellent job, don’t ever change. The evening flowed amazingly with presentations commemorating this time together, speeches from the staff congratulating the students and from the students thanking the staff, and of course the presentation of the actual badges.

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The history of the pinning ceremony is long standing, the nursing pin has a long history, dating back more than 1,000 years to the 12th century crusades. During this violent time period, those who were devoted to caring for the injured and ill were given large Maltese crosses to wear on the battlefields. These crosses with equal-sized arms were large enough for all to see.

However, it’s the legacy of the famed Florence Nightingale hundreds of years later that has influenced modern-day nursing school pinning ceremonies. Hospitals recognized Nightingale’s impact on the field of healthcare—particularly nursing—and began creating pinning programs beginning in the mid-1880s. Initially, only those nurses with exceptional marks and practice received pins, but that later expanded to a larger audience—including all nurses devoted to the welfare and well-being of society.

By 1916, pinning ceremonies were common in the U.S. and England. Since then, colleges and universities have created their own pins as well as produced their own versions of the ceremony. While some have decided to forego the ceremony and pin altogether, many continue the time-honored tradition.

Usually a separate celebration from receiving a diploma, the pinning ceremony tends to be more intimate and involves new nursing graduates and their families as well as faculty members and other representatives from the school of nursing. Some ceremonies dictate that family members pin the new graduates, while others have nursing school faculty members place pins. Nevertheless, the pinning ceremony symbolizes the graduate’s achievement of completing the educational requirements and marks their transition into the profession.

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As a final thought on the night I though I would share a portion of the key note I delivered. This section was the conclusion, and more generalised in nature.

The average life span of a nurse is just 3.7 years. It is a tough and often thankless profession that demands nothing shy of perfection every single day. It requires you to often sacrifice yourself for the betterment of others. It requires you to have the knowledge of a Doctor without the pay to match. It is a profession where you will get covered in all varying forms of bodily fluids, handle the worst that comes out of a patient, and smile while you’re doing it.  It will require you to hold back your own tears as you comfort others. You will need to juggle dozens of things at a time, and still need to make sure they all fall into place. You will be pushed by the patients to breaking point, but still deliver care with a soft and welcoming hand. You will be the first thing a baby will see, and last thing an elder will see. You will hold peoples lives in your hand as they deteriorate following trauma, and you will smile when they rehabilitate. You will write more in a shift then most authors do in weeks, and decipher more scripts than an archaeologist. You are blessed to be a part of this profession, and the profession is lucky to have you.

As a final thought I leave you with this. Nursing is a profession that requires a high level of skill and dedication. Try and take something away from every shift. Whether it be a new technique, new skill, or even a new medication, learn something. And of course try and remember, if its wet and not yours wear gloves.

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To all of those who were pinned this week, I wish you all the very best in your endeavours. For those of you who are still on the journey I wish you the very best of luck. I know I am looking forward to my Badging at the completion of my Bachelor.

Maintain the Rage

Luke Sondergeld

Five Acute Care Reflections

Over the past Five Weeks I have completed my Acute Care Placement for my Diploma of Nursing, to catch up on the day by day click here. Over that time I learnt may very valuable lessons, what many different drains can be used for, the effect of different wound care products, the differing cocktails of anaesthetics, and how diverse the multidisciplinary team really is. But given that most of that can be learnt from a book or educator I will leave those particular lessons to them. Instead, I will focus on the lessons that are picked up along the way, shared by other nurses and learnt from the patients themselves.

Time Management

We all get taught at some point during Nursing School the importance of Time Management. I have always been a fairly organised person by nature, so thought I would be ok by the time I hit the floor. Oh how I underestimated how much needs to be done, and how many interruptions to your time there will be. I would suggest that, especially as a junior nurse, come up with a time table to break up your time that suits you. I found that by the end of my placement one hour blocks were too broad, I needed 30 minute blocks to sort my time. So I would draw up the patients I was assigned with hourly columns and a diagonal line. The Left triangle would be the first 30 mins of the hour, and the right the last 30 mins of the hour. You will also need some sort of key that works for you. I used for medications, IV for anything intravenous, Dx for dressing changes or checks, Obs for any observations, BGL for any blood sugar checks, and would create others as I required them. This creates a quick reference of your night, makes handover a cinch, and means that if you get pulled away by the NUM, you can ask someone to cover the things you now about.

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Self Care

I know I have written about Self Care in my Aged Care Reflection and I feel it even more important to talk about it again after my Acute Care placement and the impacts of family, life, and the dreaded Late to Early swing. The temptation, and Lord knows I pulled this stunt too often, to simply try and live a normal life when you are on PM shift, getting off at 2300, getting home, writing for an hour, bathing and getting to bed at 0130, then getting back up at 0600 to be with the family, then proceed to stay up all day living life before heading to work by 1530. It sounds ok, till four days of only five hours sleep begins to take its toll. Sleep is key. Please ensure that you get the requisite amount of sleep. You may get away with little sleep in the short term, but Nursing is a life long career not a flash in the pan job.

Eat well, eat regularly and keep up the water. I know in the first week of placement, I wasn’t the best at keeping my fluid, and was terrible at skipping meals before or after shift. So I had to actively change the habit. I ensured that I had access to a bottle of water somewhere on the floor, as you will rarely have the opportunity to leave and get a drink, and made myself eat before and after shift. this will ensure your body will be able to deal with the coming shift, and recover from it after the fact.

Take time to yourself. I wrote two weeks ago on my Post Fall on Sword about how I was terrible at taking a moment to have time off for myself, my family or my friends. TAKE TIME AWAY FROM WORK AND SPEND TIME WITH YOUR FAMILY. I was going to be more subtle but decided that it wasn’t necessary, and would get the point across as well. The people around you will be the only ones to help you after a rubbish shift, they will be the ones that are there when you loose a child on the ward, they are the ones who will be your sounding board when the NUM rosters you for 16 days in a row then calls you on your first Sunday off in a month. Spend quality time with them, switch off from distractions and try to leave work at the door.

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Take your Time

As previously mentioned, there are a myriad of things that can drain your time during the shift. However, an extra five minutes during an admission, asking a couple of probing questions when taking observations, or simply making small talk when checking up on your patient could give you key information that would otherwise be missed. During my placement, and subsequent time in Surgical, there was a patient who was in having a hip replacement. During the admission it was discovered that they had recently completed a long haul flight six day prior. Now those two things on their own are concerning enough, however, 24 hours after the procedure the patient had a seizure, their O2 saturation were below 80% on 15L of O2, and things were looking grim. It would  later be discovered that during their time overseas they had consumed some bad seafood, had a diarrhetic episode and subsequently took six Imodium to stop it. This subsequently kept the bug inside the body and it festered away, which eventually caused the Septic Shock that the patient had suffered. Now, the nurse who admitted the patient did ask probing questions about the trip, the travel  and all other matters of questions. What was missed was when the patient stated they felt unwell on their day of travel home, the only question asked was How do you feel now? Which is only an issue in hindsight, however, for me it will stick forever the importance of asking probing questions of anything that is out of the ordinary.

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Be Personable

I spent the first 5 years of my working life, like most young Australians, in Hospitality. For most of that I was heavily involved in Wedding planning, coordinating and serving. This generally meant that for six months of the year I would plan, run and serve for over 400 weddings. As you can imagine it gets a little mundane, as each wedding, no matter how unique, is formulaic; people arrive, couple gets married, a whole bunch of photos are taken, everyone eats, there are some speeches, some people cry, some people get drunk, the couple leave, everyone stays way longer, then just before the wedding day becomes a wedding weekend everyone leaves. So after doing this 400 times you could say you would get over it. However, my boss at the time had been doing it for over 15 years. So just a few weddings. He told me that despite the fact that it may be my 400th wedding, for the couple it was their first, and hopefully only, and that stuck with me. Now, as a young practitioner, I take that lesson with me. For me it may be my 5th day on the ward, my 100th day, or heaven forbid my 1,000,000th day on the ward but for the patient it may be their first, and even if it is not the first time on the ward it may be the first time for this condition, treatment or procedure. Be a real person, talk to them about their lives, laugh where appropriate and don’t treat them like a number or another body in a bed. It is a simple lesson to listen to, but proves to be difficult to put into place when under the pump.

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No Dumb Questions

No matter how many times I hear it, no matter how many times I have tried to impart this little gem it still seems to be something that is missed. I know during my placements, my lab days at Nursing School, my study sessions with my friends, or simply asking old Dr Google, I asked a ton of questions. Some of them seemed a bit simple or dumb at the time but I soon realised that either I wasn’t the only one thinking it or it wasn’t such a stupid question at the end of it all. I recall after ECT, during my Mental Health shifts, I noticed that the consumers right eye was almost alway more blood shot then the left. I knew it was the side that the treatment runs through and assumed it was a side effect of the treatment, but asked the question anyway. It was a seemingly dumb question but raised an interesting problem, no-one know why, and more interestingly, most people hadn’t even noticed it previously. So this seemingly dumb question now moves into the realm are curiosity for many. I am still yet to actually find a reasonable answer other than because of the electricity, but I live in hope. The lesson is, NO DUMB QUESTIONS, with the sole exception of Who’s ID is this…

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Well there you have it, my Five lessons that I couldn’t learn in a classroom or book for my Acute Care placement. This brings me to the end of my journey as a Diploma Student, in a number of short weeks my registration will come in and I will be an Enrolled Nurse. Come March I will begin a new journey as a Bachelor Student as I study to become a Registered Nurse. I thank you all for coming on this journey with me far and I hope to see you all as the journey continues.

Maintain the Rage

Luke Sondergeld

Day 25

Day 25, my FINAL DAY of my Acute Care Placement, my final day in Theatre and my final day as an EN student. All in all, a momentous occasion. I saw my first set of Dental surgery, completed the last of the task book, enjoyed a nice lunch out provided by the facility and very un-ceremonously completed my placement.

The dental surgery was a fast paced, short, and reasonably simple procedure. The patients would come in, go under the anaesthetic, either have the teeth cut out, pulled out or cut into pieces, then wake up and go home. The set up and clean up were the simplest I have seen since scopes day, and the equipment list almost as short. The thing that did vary, was the method of keeping an airway. Instead of using a LMA, the anaesthetist used a Nasopharyngeal Airway. Otherwise it was a good consolidating list, though tragically cut short by my 1200 meeting with our facilitator.

The meeting was to finalise our books, sort out any last minute paperwork and hand back out locker keys. It was essentially a un-ceremonous finish to our placement. The facilitator thank us for our time and our efforts, we thanked them for their efforts and patients and we one to lunch. The facility provided us lunch at a local pub to say thank you and good bye. Two of the four NUMs attended, but had to depart early due to prior engagements, the rest of stayed for a short while then parted ways. In some ways it was a bit of a rushed end to something that had taken us so long to get to. But in other ways our Badging Ceremony we have on Wednesday is truly our finish and ceremony day.

Its been a journey, I am glad to have embarked on it. I hope you all have enjoyed reading the journey just as much as I have being on it.

Maintain the Rage

Luke Sondergeld

Day 24

Day 24 of my Acute Care Placement. My second last day at the facility, a return to the Operating Theatre and a series of new experiences. I had the privilege of sitting in on an abdominoplasty and bilateral brachioplasty first up this morning, then spent the afternoon in recovery while the three theatres were pushing out patients every 20 minutes.

The abdominoplasty and brachioplasty where both interesting in the fact that large amounts of tissue were being removed and the reconstruction of the body part following the removal. It was a time consuming procedure, both taking nearly two hours each. Most of the time was consumed by the suturing following the removal. I had the chance to handle some of the removed issue as we weighed it and disposed of it. It was oddly soft and felt like warm jelly. I remember thinking while I was holding the patient abdomen fat and skin that I wasn’t just holding useless tissue. Experiences, memories, meal, friends and family had made this fat and tissue. They where a part of the patient, and we held them in our hands. It was a surreal moment.

The afternoon in recovery was the cold shower to wake up from the surreal into reality. The patients were coming through thick and fast. The team and I were sending them back to the ward as quickly as they could be produced from theatre, and as quick a the ward could take them. It was nice to see the team of highly skilled nurses in recovery work. They are a well oiled team, with nerves of steel, an encyclopaedic knowledge and hearts of gold. Each one would care for their patient with skill, grace and poise. Tending to their needs as they arose, and anticipating the next step. It was almost inspiring to watch.

I realised today that my time with the facility is nearly at an end, and as such, my time as an Enrolled Nursing student also. I realised that I would soon be a part of this great family of nurses who dedicate their lives to caring for those in need, those who are hurting or at their worst. I am proud to stand with them, and I embrace the challenges that lie ahead in my career, my future study and beyond.

Maintain the Rage

Luke Sondergeld

Day 23

Day 23 of my Acute Care Placement, hump day of my last week, my second day in Theatre, and the day I had my final performance appraisal. Not a huge day according to the lists, with the exception of the Eye Surgeries, of which there where 27. But it was still a big day when you consider the implications of a potentially negative appraisal.

I was placed on the Scopes list this morning with a rotation through recovery in the afternoon. The Scopes list is exactly as it sounds, all of the Gastroscopies and Colonoscopies. It was biologically interesting to see the inside of someone in such close, HD detail. It was good to have the doctor explain what we were looking at and what they where looking for themselves. I have the opportunity to assist and take the samples and bottle them for analysis, a small task but enough to not be completely detached. The afternoon saw me hit recovery for the first time. It was both interesting and a change of pace. Recovery is a very one on one nursing situation, it requires attention to detail, a good knowledge base and quick reactions to physiological changes. I had the opportunity to see several cases coming out of theatre all the way through to handover to the ward. It was different, and I am glad for the experience. It was nice to actually be awake and remember what recovery is all about.

My final performance appraisal. I was a touch nervous. Not because I thought I am a terrible nurse, or can’t do the job, or anything along those line, but because I can come across as brazen, arrogant or disrespectful without intending to. In the appraisal you first make a self evaluation on a range of things, loosely based on the Nursing Standards, and give yourself a score of 1 (really bad) to 5 (excellent). I gave myself 3s almost across the board with a could 4s in areas I thought I did particularly well in. When I sat down with my facilitator, the first thing she said was You are a bit harsh on yourself aren’t you? That made me feel a little better from the word get go. The facilitator had rated me at 5s across the board. They believe that I am excelling at what I am doing, for the level I am at and just need to build the experience, by seeing different cases etc, over time. They said there hasn’t been a question asked of me where I haven’t been able to give the answer, or at least a viable way of finding the answer quickly. I was stoked.

With that behind me, registration and the final couple of days are all that is left. I am looking forward to my last two days in Theatre, I am uncertain what they will bring. But I am ready for the challenge.

Maintain the Rage

Luke Sondergeld

Day 22

Day 22 of my Acute Care Placement, and my first shift in the Operating Theatres of the facility. I was assigned one of the three theatres and given specific instructions of Blue is Bad, don’t touch blue. I was also left a little bit to my own devices as to what experience, what to get out of the day and who to follow around. I decided to make the most of it and get as close to the action as possible.

I had the pleasure of being on an orthopaedic list today, which consisted of three total knee replacements, a shoulder and a radius reduction. The list was short, the time was not, but man did it fly by. During the procedures the orthopaedic surgeon was kind enough to explain what he was doing, the rationale behind it, what we were looking at and what he was looking for. It was a great experience that I had not anticipated. Before I knew it we were closing up the second knee. I decided it would be a good time to see the same operation from the anaesthetists point of view. I teamed up with the anaesthetic nurse, and anaesthetist and started the process from entering to leaving. The anaesthetist explained what they were doing, the medication being used, what it was for, what they monitor for, the different equipment and why its used over other similar equipment. It was all in all a very enlightening experience.

The oddest part of the day was not the sounds or the sights, they were expected, but it was the smell. Specifically the diathermic device. It creates a smell that is somewhere between burnt hair, and over roasted pork. It fills the room whenever ti is used and at first is really off putting, as you realise someones flesh is being brunt just a little. But, after a while the smell becomes less intrusive and you get used to it.

The dynamic of the staff within the theatre was also interesting. Where other wards were quite clicky as a team, and worked with each other, even it was a medical vs surgical mentality, whereas surgical seems almost to be like a high school playground. Everyone is playing around but some quite nasty or demeaning things get thrown around very casually. There is backstabbing, snake like behaviour, and an almost selfish ideal shared by most. However, when it comes to the job, all bets are off and its all about the patient, but it didn’t seem to me to be the most harmonious working environment.

The first day was great, some big expectations to live up to for the next three. I would love to see an abdominoplasty, a couple of scopes, and the other odd and end surgeries the facility does. It would also be interesting to see if the different teams work differently to each other. Only time will tell.

Maintain the Rage,

Luke Sondergeld

Day 21

Day 21 of my Acute Care Placement, my last day on the Mental Health ward and my first exposure to Electro Convulsive Therapy (ECT). It was the first day on the ward that I felt truly in control, I knew what was expected and what to do fully. It is a shame that it has taken the four days t find my groove, but I am glad I found it in the end. I am also intrigued by ECT and TransCranial Magnetic Stimulation (TMS), both of which can be used to treat severe clinical depression, both use electricity but in different ways.

My day on the ward started differently to what it has the past couple of days, as I was tagging along for the ECT round this morning. It began at 0600 and started by meeting with the consumers participating in ECT, gaining their consent for the days treatment, discussing any concerns, completing paperwork and preparing them for the treatment. We then escorted them to Theatre, they where put under a light General Anaesthetic and there treatment was completed. For anyone who hasn’t seen an ECT or is curious click here. The treatment itself was slightly confronting, despite the fact that I knew what to expect, in that you are literally watching someone have an electrical signal pushed into their midbrain to cause a controlled seizure. I knew it was conducted safely, I knew the consumer would feel and remember none of it, but it was still confronting. In the recovery room I chatted to the consumers, both out of curiosity and to ensure they were waking appropriately, about the procedure and how they felt. Of the consumers that completed treatment today, they had no memory of the treatment, didn’t realise they had even gone through the procedure, and felt no ill effects from the treatment. Anecdotally, later in the afternoon the consumers that had completed treatment were the brightest and most conversant I have observed them to date. When asked how their mood was, they responded with Great, better then yesterday or similar. I was intrigued.

I had the opportunity to watch TMS a couple of days earlier, as a sort of precursor to ECT and for exposure, and it was definitely less confronting then ECT. To begin with the consumer that was being treated was awake, and the only thing that was involuntarily moving was their eyebrow, which at the time was directly beneath the magnet. I was able to converse with them while they were being treated, ask if they were uncomfortable, in any pain or felt unusual. Aside from the uncontrollable twitching of the eyebrow, there was no complaints. I was intrigued yet again. In later discussions with  one of the Clinical Nurses (CN) I learnt that ECT has about an 85% success rate versus TMS with a 50% success rate. So despite the gentle nature of TMS and the seeming barbaric nature of ECT, the results speak for themselves. If I were in the shoes of a consumer and being asked to select a treatment option, I think I would start on TMS before jumping into ECT. But, knowing that some of these consumers have fought depression for 30, 40 or even 50 years, I can appreciate and understand why they would jump to ECT, and continue with it.

I am thankful for my time in Mental Health, it has opened my eyes to a world that I didn’t think really existed. I know I entered Mental Health with expectations and assumptions, though to be honest I am still trying to work out exactly what they were. And I have left feeling educated, enlightened and better for it. Could I work in Mental Health, absolutely,  could I make a career out of it, entirely possible. Asked me that 7 days ago, and the answers may have been slightly different. Thank you to all the team, you know who you are.

Maintain the Rage

Luke Sondergeld

Day 20

Day 20 of my Acute Care Placement, my first AM shift and my second last shift in Mental Health. The day was certainly busier than the PM shifts have been of late, read day 18 and 19 to catch up, but still very different from the busy of Surgical or even Medical. I have started to see the report I have been developing with some of the consumers bearing fruit as I move around the Ward, they have begun to open up and actively talk with me about their issues, feelings, and psychosis.

I am still unsure about Mental Health, not a profession or study, but in myself. I know that the goal of Mental Health is to help consumers achieve their goals and learn coping mechanisms, stabilise their medications or enact treatment. However, I still feel like there is this massive grey area in the middle between admission issues and dischargeable acceptable goals. Though I am seeing benefit to the teaching of coping mechanisms, medication balancing and treatments as the consumers are brighter, their mood improves and they seem to able to deal with life pressures better. Though the consumers are still in a facility where they have almost everything done for them so it creates a false reality to begin with. But, I am not a psychologist or psychiatrist, so I will continue to nod and smile politely.

I am feeling more comfortable, not only in Mental Health, but with myself as a clinician. I am still asking a thousand questions a day, and will continue to into my old age, but I am more confident in my knowledge, decisions, and actions. I feel that the course and subsequent placements have actually almost adequately prepared me for what to expect. Will I still have issues, sure, will I still need time, definitely, I am still a junior clinician, I am still learning, and I am still developing, and its important to remember that.

I am thankful for my facility, its staff and all of those who I have worked with. I am particularly thankful to all the patients and consumers who were happy to allow me to practice my skills on them.

Next week will bring with it my last Mental Health shift and then four shifts in the Operating Theatre. It should be an interesting if not less intensive week then what I have been having.

Maintain the Rage

Luke Sondergeld

Day 19

Day 19 of my Acute Care placement, my second night on the Mental Health Ward, my last Afternoon shift of placement, and the start of my last Late-Early swing for placement. The afternoon was similar to yesterday, quiet, controlled, and so much different to what I have experienced thus far. The advantage I had tonight was the company of a 40 year veteran of Psychiatric Nursing as my RN for the shift.

I began the evening going through the charts, identifying the medication times, any physical observations that needed to be completed, additional notes left over from handover and any other nursing interventions that needed to be completed. Once I had the plan, we went around the ward and introduced ourselves to the consumer we would be looking after, had a discussion about what the different consumers habits, conditions and medication requirement were, then returned to the nurses station to attend paperwork. So far I have noticed that Mental Health is far more paperwork intensive then the other wards. Everything is document, re-documented and then have a progress note written about it. It is laborious and time consuming, but I am starting to realise that it is necessary.

I had the opportunity this afternoon to have a one on one chat with one of the consumers to assess their mental state, mood and general thoughts. Their diagnosis was OCD and Depression, and the conversation the we had very much pointed to that. What wasn’t documented well was the level of anxiety, it is centred around uncertainty with situation and the unease of their normal Psychiatrist being away. Their coping mechanism for OCD is currently to simply avoid, though there is no indication that the consumer has any other methods of dealing with their OCD. I felt comfortable conversing with them, I felt like to conversation was small talk loosely veiled over the questions I needed to have answered. The difficult part about the whole process is, Mental Health is all about report and relationship, I am in Mental Health for four shifts. Then I am gone. How much report can one build with a consumer in such a short time, specially when the level of exposure to mental health up to this point has been minimal.

I am enjoying my time in Mental Health because it is so different from what I have done previously. I can see why some people find it comfortable, appealing or suitably challenging enough for it to become a career. Do I think I am at that point, time will tell. I have two more shift, the first being at 0700 Friday, so maybe something will change, or I will become super aware of Mental Health and how I can fit into it. But for now, I think that the exposure I am getting is only sufficient enough to know roughly how the ward works.

Maintain the Rage

Luke Sondergeld

Day 18

Day 18 of my Acute Care Placement and my first shift on a Mental Health ward. I didn’t quite know what to expect from this afternoon. I didn’t quite know what my role was going to be. I knew that I was going to be dealing with complex and numerous medications, emotions that were on a knifes edge, and triggers from consumers (Mental Health Patients) that vary from noises, to visual cues, through to hallucinated triggers.

I like the back and white. I like when there is a problem, that there is a solution. That’s why I prefer Maths to English as a subject, and why I have an affinity for Medical and Surgical. If someone comes in and they are bleeding we stop it, if they have a broken leg we set it, if someone comes in with brain that isn’t doing what it is supposed to be doing… well thats where the grey comes in. And I don’t deal well with shades of grey. It is a hangup that I have to deal with, and even in my brief stint so far in Mental Health, I have begun the journey to overcome it. I understand that Mental health is a very different game, everyone is unique and their treatment is just as unique. No two depressions are the same, no two PTSDs are the same, and they aren’t treated the same.

Another thing I will have to get used to is the pace. Having just spent eight days on the Surgical Ward I have been used to achieving what needs to be achieved in a  polite and courteous manner and then moving on, with 20 other things happening at the same time.  Mental health is not like that at all. Though there are still things that need to be achieved, it is at a slower pace. It is a calm, quiet and sedate environment that allows for open communication and a report to be built between the consumers and the staff. I think with time, and proper tutelage, I could flourish in Mental Health, and with more and more Mental Illness being present on other wards, it will serve well in the future.

Tomorrow is a new day, a new outlook and a better equipped student who knows roughly what he is getting in for. I am thankful that the facility I am in allows the rotation of the student through the various areas, I am glad I have the opportunity to see Mental Health, outside of the placement environment I don’t think I would have voluntarily stepped foot inside the ward. Tomorrow will be a good day.

Maintain The Rage

Luke Sondergeld

Day 17

Day 17 of my Acute Care Placement and my last shift on the Surgical Ward. The ward was packed, and I mean not a bed spare, hot swapping patients within an hour of discharge, sending them onto other hospitals for rehabilitation. Proper busy. As a final shift, and pseudo send off from the ward, it was finishing on a high note.

I took three patients as my own, and between myself and the AIN made sure all the cares, observations and the like were completed. I then liaised with the RN to ensure I could complete the medications required, while still availing myself to the interesting learning opportunities on the ward as a whole. It was fun, I thoroughly enjoyed myself, not to mention I felt at home, I didn’t feel anxious, nervous, or out of control. I felt like I was another cog in a well oiled machine. It was nice.

Something thing of note, I completed my 20 hours of required Medication time tonight. Which doesn’t mean I stop being involved and trying to get every available subcutaneous, intramuscular injection or otherwise, but I am no longer burdened by this looming target that I have to reach, especially with my move to Mental health tomorrow and Theatre early next week.

I enjoyed my time in Surgical, I enjoyed the pace, the teamwork, the diversity, the structure and the process. I feel that from a time management perspective, Surgical would be a great ward to work in following graduation. However, I feel that for maximum exposure to different, unique and sometime complex health situations Medical won hands down. But having said all of that, my facility is only small, it only has the three wards and theatre, it doesn’t have an ICU, HDU, Oncology, Cardiac, Paediatrics, Neo Natal, Rehabilitation or Renal unit. Without exposure to all of these wards or units, I don’t feel I will ever truly be able to find my favourite place. And having said all of that, every ward, section or unit has its positives and negatives, all of them are potential learning outcomes and growth points, and thats what I love so much about Nursing, its diversity and the ability to grow and learn. A profession like no other.

Tomorrow afternoon will see my first Mental Health shift, I am a little apprehensive as I am not a massive fan of shades of grey. I like black and white, that leg is broken you need a cast, but if someones head is broken its not so easy. Of the four wards the facility has, I feel that Mental Health will push me the most, not because of its overt complexity, busy schedule or heavy physical demand, but because it is such a different style of nursing to what we are taught, and different from what I feel I am good at. A good lesson in self discovery shall be had.

Maintain The Rage

Luke Sondergeld

Day 16

Day 16 of my Acute Care Placement, and my second last day on the Surgical Ward. Not knowing what to expect from a Monday evening, I didn’t go in with any level of expectation, when I arrived I went through the list of names and beds, checked against the surgery list and endeavoured to plan out the evening as best I could. That was almost useless. Theatre by the end of my shift, was operating nearly four hours behind. Patients were only being seen at times we thought they would be returning. This made for a slow and disrupted afternoon.

I was allocated eight beds with one of the RNs and we set out to check charts, make notes about medications, check care plans, have a chat with the patients to identify habits and needs, and generally get our things organised. All in all the afternoon was going to be constant but nothing crazy. We set to our work. Having a very experienced RN with me for the afternoon made things very efficient, we worked well as a team and achieved what we needed to achieve in little time. This left us with ample time to assist those who had returned from theatre with getting comfortable, rearranging linen and lines, and generally tidying them up post-op.

My heartwarming moment of the day was seeing the patient previously written about in Days 14 and 15 up and walking about. They are so happy to be moving around, and eternally grateful with things like I wouldn’t be here if it wasn’t for you lot being said to almost every nurse on the ward. It was good to see such  positive result out of a potentially life threatening condition.

I did have, what I consider, to be the best compliment an EN student could be paid by another staff member, paid to me this shift. As we were packing up the files, handing over and generally debriefing the shift one of the RNs asked what I would be doing post graduation. I explained I was going to be studying my Bachelor and working as an EN. They then said Wow, I thought you were an RN student, you seem to know so much already. This sentiment was echoed by several of the other staff I was working with that night at the same time. I was chuffed, I’m not going to lie I think I even sat up a little straighter. It is so good to be told that you are on the right track, that you have the requisite knowledge or skills. I still feel that I don’t know enough, and in a way I pray I never do.

Tomorrow afternoon is my last afternoon on Surgical before moving over to Mental Health. A new ward and a new set of challenges.

Maintain The Rage

Luke Sondergeld

Day 15

Day 15, the end of the third week of my Acute Care Placement, and my first afternoon shift on the Surgical ward. I didn’t know quite what to expect from an afternoon shift on Surgical, however with an emptying ward, no new admissions, only two theatre cases and most of the patients being day three, I wasn’t anticipating a busy shift.

The shift began just as any other, with handover, it was nice to be on the receiving end of  a bedside handover for once. We then proceeded to the oddest part of the afternoon shift, after signing on 30 minutes prior, we go to afternoon tea, then return to allow the morning staff to leave. We completed our medications rounds, completed observations, changed wound dressings and planned out the afternoon and early evening. But even with all of the pressing, and not so pressing, cares completed we all still felt this unnerving and uneasy calm across the ward. We all checked out patients again o ensure they were all comfortable and didn’t require anything. We were going to be in a, I can say it now because the shift is over, quiet night. It almost seemed that we would have 10 minutes of work then 50 minutes of wandering around fussing over empty rooms, tidying up the ward, preparing the next shift and the next day, organising charts for the two surgical cases the following day, and generally cleaning up the ward. It was not time wasted as the staff took the opportunity to discuss some of the decisions that had been made with various patients, medications, procedures and honing of the critical thinking we all get hammered with in nursing school.

An interesting development with the patient mentioned in yesterdays post. The original diagnosis for the patient was a Pulmonary Embolism as the CTPA returned the possibility. However, following early blood cultures, and other blood results, it was later determined that he suffered from septic shock. The Doctor even went as far to say that if it wasn’t for the quick and thorough actions of the nursing staff yesterday that the patient may not be alive today. Chalk one up to the good guys. The current theory is, the patient travelled overseas and consumed some of the local water, had episodic diarrhoea which the patient took an exceptionally large dose of immodium for. The bacteria that caused the initial diarrhoea was then left in the body and eventually infected his bloodstream. The patient is now doing much better, though is still being closely monitored by both the Doctor and the Nurses.

I still have another two afternoon shifts in Surgical before shifting over to the Mental Health ward. But for now I am going to spend some much needed time with the family.

Maintain the Rage

Luke Sondergeld

Day 14

Day 14, for my Acute Care Placement and a return to the Surgical Ward, for what was is my last AM shift before a three day stint on the PM.  The ward was surprisingly empty, compared to the chaos that was yesterday. There were several discharges, a fair spread of second day orthopaedics and abdominoplasties, and a day two TURP. I would have the inordinate pleasure of being assigned the patients at the end of the passageway, the furthest point away from the Nurses Station.

The day began really well, I was with the RN with five patients, we checked on the patients, delivered their morning medications and analgesia, I assisted the RN with IV therapy and antibiotics as appropriate. The morning progressed, we went to morning tea and returned to assist with physiotherapy, post morning ablutions and showering. As I was assisting a patient into the shower, the Emergency buzzer was set off. I ensured my patient was safe and left them in the hands of their partner. I walked out of the room to find it was the patient next door. There were people everywhere. We alway talked about it in class that every man and his dog rocks up, but they weren’t kidding, Doctors, Nurses, Physios and even the Pharmacist rocked up. The situation was the patient was returning to bed following a shower and they began to convulse.  After taking observations it was noted their Oxygen Saturation was below 75% and was barely staying at that point on 15L of O2 with a Non-Rebreather mask. After settling the patient enough and stabilising the oxygen saturation on Nasal Prongs, a portable Xray of their chest was ordered to rule out a clot. A CT Pulmonary Angiogram was also ordered to determine the extent of any such clot.

The day progressed, we monitored the patient like a hawk, with observations being conducted several times an hour, the doctor visiting from time to time to write up orders and to check up on the patient. The day progressed and the patient remained reasonably stable, till about 1500 just after handover their BP crashed to 80/40. They were left in the very capable hands of the afternoon shift and the day was done. It was oddly exhilarating going through the whole process, the stabilisation, the investigation, the monitoring, the diagnosis, and the care of both the patient and the partner. I am thankful for not only my training received at CQUniversity but my time in the Navy that prepared me to deal with the situation and the people involved.

Tomorrow will be an interesting change moving to the PM shift on Surgical, but I am looking froward to the challenges that lie ahead.

Maintain the Rage

Luke Sondergeld

Day 13

Day 13, Hump Day for my Acute Care Placement and a return to the Surgical Ward, for what was promised to be a busy day. And it didn’t disappoint.  The ward was full, there where four patients on the waitlist for a bed and 90% of the patients on the ward were only One Day Post Op. I was assigned two patients at the end of the ward, and assisting the RN and EN with the other six, where possible.

I arrived this morning early to check over the days list and see what was happening, given we had been worded up by the admin staff that today was going to be a doozy. I was running over the list and almost immediately saw what they meant. It wasn’t the number of surgeries booked from the ward, which was only five, but the sheer number of IV antibiotics, drains, VTE prophylaxis, post operation medications, catheters, fluid balance charts, physiotherapist reviews and subsequently paperwork associated. Then onto handover, not much that was overly surprising but good to know we were due to discharge five patients before lunch, so we can fill the beds up again.

My two patients were great, one abdominoplasty and one total knee replacement, both first day post op, both busy in their own right, the other six were no easier. I set up my plan, I got organised and the first snag of the day, intravenous (IV) therapy, IV antibiotics and Schedule 8 (S8) medications. I needed two staff, at least one RN before I could even start my day, and even then I couldn’t really do any of it, even if I wanted to. I set out to help as best I could, I delivered the S8 medications with the RN, gave out my other oral medications with the facilitator, made beds, showered patients and helped the physio staff. I got done what I needed to get done, but I was busy trying to do it, and I was only made busier by having to find the staff I needed to be able to do the task I set out to do.

I felt today that I was doing nothing but disappointing my facilitator, not because of any massive error, or laziness, or misdemeanour, but just a feeling. When we were handing out medications they handed me the two cards I needed, I saw them pull them out of the cupboard, out of the box and hand them to me, I then dispensed the medication, checked the ID and 7 rights of the patient and moved on. After the fact I was asked if I checked the expiry date on the card I was handed, I did not. They pointed out I should have, which I totally agree with, and that even though someone else may have checked the expiry, in this case the facilitator, I shouldn’t rely on or trust that it is done correctly. Later in the afternoon when it came time for writing progress notes I went to the nurses station to write my patients noted only to find that the fastidious nurses that I was working with had already written them. The facilitator comes round to ask if I have written the notes, I explain what has transpired and they simply say Oh well, do them tomorrow then. I know that it was probably nothing, and I know that the facilitator wasn’t being mean, malicious or callous. I just think that the placement, my final placement, the study, the light at the end of the tunnel is all getting to me a bit and I am starting to see little things in people, mannerisms, and reading too much into them. Tomorrow I think I will try and relax and just care for the patients worry about the rest later.

Tomorrow is my last morning shift with Surgical before a swing onto the afternoon shift for Friday and Monday, then onto the Mental Health ward.

Maintain the Rage

Luke Sondergeld

Day 12

Day 12 of my Acute Care Placement and my return to Surgical Ward. After a wonderful, if not busy 8 days in Medical (Days 2, 3, 4, 5, 6, 7, 8 and 9). Today saw me be assigned a patient to be responsible for, a new admit, and a  support role for the RN on the ward. It was listed to be a busy day, with the return of an Orthopaedic Surgeon and a two patient wait list on top of the other admissions planned for the day.

Firstly, the patient I was assigned. I was looking forward to it. I paid attention to the intricacies in handover, I checked the chart to ensure there wasn’t anything I missed, planned out medications, the works. As I was sussing out my admit who was due in a little later in the day, the Doctors completed their rounds. I returned to my patient to see if they needed anything, take some observations and generally care for the patient. To find she was being unexpectedly discharged. Which threw my entire plan out the window. Instead, I organised an outpatients appointment, sorted her paperwork and that was it. Done and dusted by a little after 1000. Reminds me of an old Navy saying, remain flexible.

My admit, my first solo for surgical, arrived at around 1200, for a 1400 operation. I bought them in, went through the paperwork, weighed, observed, measured and prepped the patient. I thought I was doing really well. I had my paperwork checked by the RN who pointed out some minor things I missed and felt really chuffed. Till I saw how long it took. Just under an hour. In school I thought I was doing pretty well, my practice admits where down to under 20 minutes. I put it down to several things;

  1. Real patients don’t anticipate answers like nursing students
  2. I am still trying to work my way around the facilities paperwork, as it is significantly different from what we have learnt
  3. This patient was complex, not just because of their history, but because every time a question was asked it seemed to either contradict a piece of information, or reveal something new.

However, this is the real world, and I need to be able to shorted that time to under 30 minutes. Something to strive for.

The rest of the day seemed to disappear. I think I looked at the clock to actually check the time three times, not including for documentation, and it seemed to go something like; 0830 to 1145 to 1430 in two blinks.  I am thoroughly enjoying my placement and my time in Surgical.

I also had my mid-placement review with my facilitator. I was a little nervous. I didn’t quite know what to expect for my first acute placement. I sat down with the facilitator, we discussed the time I have had, what I have learned, and how everything is going. They then told me that I am doing really well, that’s a relief.  They told me that I have the knowledge, I have it squirrelled away in my brain, and I just need the experience to polish what I know, with some clinical time, to produce a great result. It was a nice little boost for the afternoon, and is a great encouragement to continue on this placement, and into the future.

A return to Surgical tomorrow, to deal with the 24 hours post op cares, should be an interesting day.

Maintain the Rage

Luke Sondergeld

Day 11

Day 11 of my Acute Care Placement and my return to Surgical Ward. After a wonderful, if not busy 8 days in Medical (Days 2, 3, 4, 5, 6, 7, 8 and 9). My day was less about assigned patients, as I was buddied with another EN, and more about getting things done, getting exposed to some new procedures and supporting the team.

The EN I was buddies with was great, they had recently been employed by the Facility following their placement with the facility some months prior. They were knowledgable, friendly, respectful and willing to educate on some local procedural things and Nursing tips in general. We worked well as a team, dividing and conquering where we could, and buddying up where appropriate. We admitted patients, discharged them, prepped for theatre, observed, documented and generally Nursed away the day, which seemed to evaporate again. They were a pleasure to work with, and look forward to spending time with them tomorrow.

I had the opportunity to remove a Jackson-Pratt drain from a patient, following their abdominoplasty. The procedure is simple enough, it involves releasing the vacuum from the drain, cutting the anchoring stitch, and removing the drain by pulling it out of the body. Simple enough. Only the Facility I am at perform the task differently. Instead of using the wound tray and tools inside to handle the drain, wound or otherwise, they add in Sterile gloves and a whole new series of steps. With normal gloves, you prepare the area, move your drains around and other dirty tasks. You wash and don new gloves, open your wound pack and clean the area with saline and swabs. You then de-glove, scrub up, and don sterile gloves, which you then use to hold the drain with a pair of forceps, cut the stitch, pull the drain, cover with gauze to ensure there is no leaking then bandage appropriately. Because this procedure was different to what I was expecting, I looked the right goose in front of the patient as I was almost coached through the procedure by my facilitator. Lesson learned, talk before the procedure to ensure there are no massive differences in technique.

I felt accomplished by the end of the day, despite the fact that I don’t know where the time between 0930 and 1430 went. Tomorrow promises to be not only a good day, but an even busier one, with one of the Surgeons returning from leave and taking up patients again. I am looking forward to the challenge.

Maintain the Rage

Luke Sondergeld

Day 10

Day 10 of my Acute Care Placement and my first day on the Surgical Ward. After a wonderful, if not busy 8 days in Medical (Days 2, 3, 4, 5, 6, 7, 8 and 9), I and the rest of the Students, have been rotated  to different Wards. It was also my first experience of a Late-to-Early swing, finishing at 2300 the night before and starting again at 0700. I am not going to lie, I was a little rough around the edges this morning and could have very easily gone back to bed. But, I persevered, arrived early and eager to do my best.

Handover was much the same as it is in Medical, except there are nearly twice as many patients, and thankfully twice as many staff. The turn around times are significantly shorter and the focus is less on diagnostics and treatment, and more on preparation and recovery, which was to be expected. There where all sorts of post operative patients, abdominoplasties, laparoscopic cholecystectomies, joint replacements, wound debridement and management. So many varied procedures, and subsequently varied post operative cares. The medication rounds tended to be easier, with most people being on analgesia and maybe a couple of medications from home, as apposed to medical which wasn’t unusual to see 15-20 medications for a single patient.

The wound care, however, more than makes up for it. Every single patient has some varying form of wound, from a couple of small openings from a laparoscopic procedure, to a long incision and wound from an abdominoplasty. Wound care is fascinating. Time consuming, but fascinating. I have aways loved wounds, their treatment, what can go wrong, the ways to remedy a deteriorating wound, it is all interesting and different. Most of the wound are fairly simple, a clean and new dressing every couple of days, and they are fine. Then there are the chronic wounds, skin grafts, and dehisced wounds. They are not so simple. I enjoy learning more and more about wounds and post operative care. Today was a really great insight into a ward that can at time be chaotic and task orientated.

Nursing is never dull. Ask any nurse and they will tell you there is always something that  pops up that you just can’t help but laugh and smile. Today I had a patient come out of their room, and quietly say she had a problem, several nurses who were standing close by all turned around as I asked what was wrong, their analytical minds already turning over in anticipation. They then, very bashfully, say I have lost my knickers out the window, can somebody help me. Professionally we all share in the chuckle and I go out the front of the facility to retrieve the patients undergarments. Thankfully their window was open so I could return them to the patient without having to carry them through the ward, for everyone to see. Never a dull moment.

I am thankful for a quieter day today, both because I am on a new ward, and because I was exceptionally tired. I am looking forward to the next seven days I have in surgical and the lessons I will learn.

Maintain the Rage

Luke Sondergeld

Day 9

Day 9 of my Acute Care Placement, my last night on the Medical Ward, and what a night. The night started much the same as any other, we had enough staff, we were in control, everything was running OK. Then an overflow surgical admission hit our floor, and a new medical admission, then the Theatre was ready for their new patient, and a patient was hypertensive with no action helping, Doctors came and went with their new orders, and the night somehow… vanished.

I arrived to the facility early, as I always do, looked over the patient list, had an informal chat with one of the other Nurses, caught up with the AM Student on the Medical Ward and awaited handover. Handover went well, nothing spectacularly out of the ordinary, most of the patients were the same and stable. Medication rounds, observations and the start of the evening ran smoothly. We went to dinner. Then everything changed. With what seemed like a small increase in workload, the ward slipped into a madhouse. Instead of the cool, calm and collected Nurses I had been working with, we were all now flat out and juggling patients, medications, admissions and transport. Which wouldn’t normally be a problem, but when so many tasks have to be completed by an RN and you only have one, things get busy. So the EN and myself set out to be as useful as physically possible. There were no longer assigned patients, just cares that needed to be attended.

The most frustrating thing about the whole ordeal, was my limited scope of practice.  I could see what needed to be done, I relayed them to my RN and EN counterparts, and I could do none of it without the RN. So I did what I could. I took the observations, I moved, rolled, assisted, changed, wiped, and emptied everything I could to take the burden off the other two. We worked well.

Overall the night may have been chaotic, and busy and non stop, but I loved it. It was exhilarating to see this well oiled machine of a hospital get into gear and just do. It is uplifting to know that I can do this Nursing thing, when I have the scope to do it. It is great to hear praises and thanks and well wishes from the other nurses on my effort, ability and future.

I am happy to be called a Nurse, and even happier to serve as one

Maintain the Rage

Luke Sondergeld

Day 8

Day 8 of my Acute Care Placement, and I’m still on the Medical Ward, though not for much longer. Today was one of those days where I should have gone back to bed and rolled out of the other side. I had to try hard to focus, and if I didn’t, I would forget what I was doing and miss a step. Today was also one of those shifts where you walk on the ward to almost chaos, staff are blurs, voices can be heard from everywhere and the paperwork is still sitting in the nurses station. I should have taken that as a hint that it was going to be an interesting shift. I did not.

Off shift, I noticed that I was having a bad memory and focus day when I would start chores and leave them half done, enter a room and forget why I was there, and when I had to check three times when I had to be on shift, when I have had the same start time all week. I tried to Caffeinate Up and push through, but that was only a stop gap measure. I was going to have to focus today. Thankfully, by the time my shift started I was ok, I forgot some minor things, nothing medication or cares related thankfully, but little things like forgetting to come back with that bottle of water, or not finishing a sentence. The end of my shift, however, I did let my mind wander again and I wrote the notes for a patient, in another patients chart… to my defence, they had the same last name, approximate age and file size, however it was a large enough mistake for me to forcibly switch back on and refocus.

Today was my first shift with four patients, and the RN only watching over me, without prompts or assistance. It went well, I felt like I was in control through the shift, I was still able to assist the EN with her load when she asked for it, or attend her patients calls when she was busy. I felt accomplished. The RN seemed to be pleased, and when I asked how I was doing she simply stated You’ll be fine, you are knowledgable, kind and personable. A good little boost for the middle of the shift.

The shift its self seems to dissolve away just as quickly as 2017 is seeming to be doing. We started at 1430 with handover, had a Ward Meeting at 1500, then hit the floor, before I know it, it was 1800. I had completed all the medications, observations, cares and what not that I was required, all the patients were happy, but time just trickled through my fingers. Additionally, every task on the shift seemed to take longer than anticipated. A simple assist to the bathroom becomes a 30 minutes evolution when the requests begin, and additional little tasks the patient has saved up for your next visit. However, the shift went well, everything was attended as appropriate, I handed over the patients I had at the end of my shift, with some additions from the RN on matters of Blood Results and other information handed over to her that I was unaware of.

I look forward to my last shift on the Medical Ward tomorrow, it will be sad to leave the patients I have come to know, and I will miss seeing their progress and eventual discharge. However, I will still receive news from my student friends who are rotating with me from other wards. So that is comforting.

Until tomorrow, Maintain the Rage

Luke Sondergeld

Day 7

Day 7 of my Acute Care Placement sees my Second Late shift on the Medical ward for my Facility. The staff are becoming more familiar as I work with nurses I have previously, the processes are beginning to become more streamlined as I continue to work with them, and even the Patients are beginning to become a little more familiar, as some of them are in for a long stay.

I am feeling more comfortable on the floor. I arrive early, just as I have always done, get myself sorted personally, grab a copy of the patient list, being identifying who is who and what has changed since my last shift, draw up my work table on the back of the sheet, note down the highlights of each patient like observations, medications and anything else that needs attention, then get ready for handover. I listen to the handover to pick up any new details that I don’t know, or isn’t clear in the chart, I listen for patterns in behaviours and observations, and I make more notes. I then get my patient allocation, which continues to be three with the addition of assisting the RN with her medications and cares, and helping any other staff out where possible. I am finally in my groove. I feel like if I could work within my scope as an EN, without the need to be shadowed constantly, I could comfortably look after three patients. Perhaps I will ask for more, though feel I am already unofficially doing it with the RN begin my shadow.

The patients are remembering who I am, and I them. I am identifying and acting upon their habits, behaviours, and trying to anticipate need vice reading to need. The patients feel comfortable with me as a Nurse and don’t see me so much as a student anymore. I have had my first rejection for care tonight however, a female client had a urinary bag attached to collect a sterile specimen, when she buzzed to have it checked and I arrived, she promptly asked for a female nurse. Now, it is completely her right to request any nurse she wishes, and I in no way took offence, but it was however notable. I find as a Six Foot Two male, that I have to be almost overtly kind and compassionate to compensate for my gender, height, and overall size. Most patients though, haven’t had a bother. I have performed two ECGs on females, inserted a catheter into a female patient, and the three patients I have been solely responsible for are all female. So on the whole, I feel that people are seeing me as a nurse, and not anything else, which is pleasing.

I did have a deep swallow moment today however. I have a patient who I cared for during my Aged Care Placement, they came in with lower limb cellulitis. On admission it was limited to the distal end of their left leg. Now it consumes most of their left leg and is beginning to develop on their right. This in its self was not the trigger for my deep swallow. What was the trigger, was the last time I saw something like this, was one week before my Nan passed. She had cellulitis in her lower legs, and was flow to Brisbane, she passed just over a week later. Now it wasn’t the cellulitis on its own that took her, there where a myriad of reasons behind that, but it did touch on a sore point, and I had to stop and compose myself before continuing on. Given the fact that nobody said anything, I am going to guess I got away with hiding it.

So for a reasonably quiet shift, it was a good reflective shift, it allowed me to look at my practice, my time management and my nursing cares. I am falling in love with this profession more and more every day, and am so grateful that I have the opportunity to be a part of it.

Maintain the Rage

Luke Sondergeld.

Day 6

Day 6 of my Acute Care Placement saw the return to the Medical ward, however, this time was the Afternoon shift, 1430 till 2300. The shift began with a in room handover of the all patients, and then oddly, 30 minutes after beginning the shift, afternoon tea. I was assigned three patients, two of whom were on contact precautions, and one with a Intravenous Antibiotics, which I am one allowed to monitor and report on, not actually hang and administer.

I am still puzzled by the choice of having afternoon tea so soon after the shift begins, and after watching the shift progress there are far better times to have a break, however, this is what the facility does, and who am I to argue.

The management of the patients went better then any shift previous, I had the medications rounds sorted, I checked the medications I was unsure of, I knew what was happening and when, and still had time to assist with the other two patients of the RN who was supervising me, and their medications and cares. All in the name of experience, help and education.

I feel more confident on the ward, I feel like I am getting to know the position, how it all works and who is who when it comes to complex cares. The part I am finding difficult is end of shift notes. I can complete the care plans, assist with the drafting, admissions, discharges, and the risk assessments that come with them. But when it comes to writing a few lines at the end of the shift to summarise what happened. Nothing. I draw a blank, I look over the observations, my notes, go over what happened, and struggle to squeeze out a sentence. I suppose in the end of it all, I am struggling because it seems pointless to write Patient existed, nothing happened in spite of constant checking. We as nurses fill out numerous different reports, plans and pathways on a patient, we document everything to the nth degree. And then right at the end we draw a little word picture, covering everything that is written on everything else. Even if something different happens, and you take an action, that is still documented elsewhere, and we still write about it. I know it is something I will have to get over, and get better at, but it still irks me.

This week sees me staying in Medical until Friday, at which point I move over to the Surgical Ward, and the busy times to had there.

Until tomorrow, Maintain the Rage

Luke Sondergeld

Day 5

Day 5 and the end to the first week of the Acute Care Placement, so much learnt and still so much to go. This week has seen so many polished skills, improvements on time management, patient care, and assessment ability. The facility and its staff have been extremely accomodating, patient, and nurturing towards not just myself but the other students as well. The staff afford every opportunity to be exposed to new procedures and give the students a go, often at the expense of efficiency, but never at the expense of patient care.

Today saw a return to the Medical ward for my last Early Shift in the ward, as I will be swapping to the Late Shift from Monday to finish my eight days in Medical. I assisted the RN today with a case load of six patients, two Discharges and three new admits. I monitored a blood transfusion of two units for a patient, completed medication rounds as normal, and completed two ECGs. All together it made for a busy day, but manageable, though having a great RN to work with made the job infinitely more manageable.

Other than the obvious learning previously mentioned, I had an interesting encounter with several of the patients today. Firstly, one of the new admits was a client from my Aged Care placement in 2016, which was kind of surreal. When I last saw the resident she was reasonably healthy, for someone of their age, and it was almost saddening to see them in an acute setting, knowing that their health was deteriorating. In a lot of ways it was a physical representation of the deterioration of the human body as we age, and how sometimes its the mind that lets go, and sometimes the body. It was uplifting to see that the resident was their upbeat, happy self, and that they where in good hands.

During the monitoring of the Blood Transfusion, I took the opportunity to chat to the patient and his wife while I was taking observations, to pass the time for all concerned and to distract them both from the procedure. While talking with them I found out that the wife was a retired RN, and the husband an Army Veteran. We talked about their various conditions, which turned out to be great learning opportunity, and while taking the observations I witnessed a mild fluid overloading, which was characterised by an increase in systolic blood pressure and relieved by passing urine and increasing movement.

Currently on the ward is a palliative patient, as there isn’t a designated ward in the facility. The patient has end stage bowel cancer, with a descended abdomen, fluid collection in the lower extremities, decreased input and subsequently decreased output. They are in the final stages with a subcutaneous infusion, and pressure area care being the only real nursing interventions being undertaken. As someone with an interest in palliation, I ensure I try to extend the comfort afforded to the patient to their family as well. It is something I firmly believe in and thankfully observe the other staff at the facility undertaking as well. Palliative care done right warms my heart.

All in all, a busy day, that was extremely rewarding, and though I feel exhausted, for placement reasons and non placement reasons, I feel invigorated at the same time. Every day I spend on the floor, is another reassurance that I am in the right place, and I am answering my calling.

Until Monday, Maintain the Rage

Luke Sondergeld

Day 4

Day 4 of my Acute Care Placement was an Introduction into routine, management and additional skills. I was given two Patients to by the NUM as my case load for the day, with the additional instruction Anything else interesting that comes up, which tickled my curiosity and intrigue just a little. The patients I had assigned weren’t overly difficult, but had large amounts of medications and high level personal cares. I also had the opportunity to complete a surgical admission, and see it through to handover at the theatre doors. I also had the opportunity to insert a Indwelling Catheter on a female patient for the first time.

Having a patient load of my own was a great opportunity, and a great learning opportunity. I took the time before I started to look over the medication charts to see when medications were due and make notes accordingly, I noted any cares requirements or additional tasks that needed to be completed by the end of my shift. For the most part I managed the day well, I was a little late with the 1400 medications as I was inserting the aforementioned catheter. But otherwise managed well. A great learning curve for the day, and a chance to push myself tomorrow and see if I can juggle the addition of another patient.

The Indwelling Catheter was a rare opportunity for my facility, as most are inserted in theatre, or patients come into the Medical ward with them already. I had supervision from our preceptor RN and had the other two students on shift with me to assist and observe. I was a little nervous heading into my first catheterisation and a female to boot. What made matters worse was the constant chorus from the other nurses about how hard this particular patient was, which in addition to females being harder in the first place, didn’t fill me with the most confidence that I would be able to nail this. However, I set myself up in the room, had my fellow students position and hold the legs slightly apart, and with some conferring with the RN inserted the catheter first time, collected the MSU I needed, inflated the balloon and exhaled deeply with overwhelming relief that I didn’t miss, or more importantly, put undue discomfort on the patient.

All in all, a great day. A good confidence boost for my time management, skills and procedure knowledge, and patient cares. I feel that in the past four days I have learnt more than in the proceeding four weeks. And I am exhilarated because of it. Each day brings with it a new sense of adventure, challenge, knowledge, growth and personal discovery. Definitely picked the right career here.

Looking forward to another great day tomorrow, Maintain the Rage,

Luke Sondergeld

Day 3

Day 3 of my Acute Care Placement saw a complete shift from yesterday, there were two RNs on Shift, plus the Nurse Unit Manager (NUM). It made life so much easier for skills, assessments, medications, procedures and patient care. I was free to do more with the patients as I had the supervision I needed to legally perform the tasks. I seem to be learning more and more everyday, which I expect to do for the rest of my career, and it seems that no matter how much I seem to learn, it still seems I don’t know enough.

Unlike yesterday, I started on the floor. We completed handover with the evening staff, then dove straight into the morning routine. Wakes, observations, showers and 0800 Medication Rounds. In School we discuss polypharmacy and its impact on patients, what it is and how it occurs. Today I witnessed polypharmacy and how much harder it can make your job. Two patients had over 12 medications, just in the 0800 medication round and nearly 20 different medications by the end of day. It stretched my mind to remember all of the classes of drugs and which ones I was giving out, what they were for and looking up the ones I hadn’t heard of before. It was time consuming and very rewarding, and I am eternally grateful for the very patient RN I had supervising me.

I was given two patients for the shift that were my responsibility, in some ways I felt I did quiet well, I stayed on top of observations, preparations for theatre, discharge preparation, medication administration and personal cares, but in other ways I felt I was inattentive. I am sure it was either my own mind wanting to give them my undivided attention, but as the ward was as busy as it was, and there were blood transfusions, Vac dressings, subcutaneous injections, and other complex or rare procedures to be completed and experienced, I felt I was abandoning my patients. But I know that if at any time I was being truly neglectful the RNs on duty would have curtly reminded me of my duties, or prompted for me to ask for assistance… read You have forgotten this would you like me to do it for you.

I completed my first Fleet Enema on a live patient, vice a latex manikin, which was both interesting and far less daunting then I expected. I am finding the more skills I perform on actual patients, injections, suppositories, assessments, or otherwise, the more I feel reassured that I am actually helping them and not infact inflicting discomfort, pain or general unpleasantness upon them. It is nice to know that what you are doing is having a positive impact.

I experienced my first interrupted meal as a Nurse, even if I am still a student. I was taking the opportunity to take a lunch break between 120 Medications and the afternoon activities prior to handover. I make it to the break room, make a coffee, finally get to the front of the microwave queue and then another staff member comes around the corner and says Medical just called and they are about to start the Blood Transfusion. The blood transfusion I have been waiting for all day. I take my lunch out of the fridge, place it and my coffee on top of the fridge, and race back to Medical. Some 2 hours following the procedure, the myriad of observations that need to be done following and the satisfaction that my Patient is not indeed having an acute reaction to the blood, I return to the lunch room…. Two hours later.

Outside of placement, after clocking off at 1530, I raced home to cook dinner for the family, showered and changed into another Uniform for Scouts and left again by 1730. I returned home, tired, sore and sweaty at 2030, where I now write about my day in my Blog for you the reader to enjoy, it may take a while to get used to regular 14 hour days.

All in all though, it was an amazing day. I learnt a ton about procedures, skills, medications, diseases and conditions, but I also learnt more about myself, my place in the world of Nursing and the same constant reassurance I receive knowing that I am where I am supposed to be.

Until tomorrow, Maintain the Rage

Luke Sondergeld

Day 2

Day 2 of my Acute Care placement saw me finally hit floor, after a brief 2 hour induction into ward routines, paperwork and documentation. The induction was good as it gave us all an understanding of the different paperwork and documentation requirements of this facility. The Medical ward, in which I am completing my first 8 shifts, was in a little bit of chaos as it was combined with the Surgical ward until early this morning, at which point all of the patients where returned to the Medical ward, with little to no handover and several new admits.

The induction was detailed and informative, it alleviated some of the tension and answered some unknowns. It was good to cover the different paperwork and have a chance to talk to the Registered Nurse (RN) about what it all actually meant, and to be able to see what the expectation was before hitting the floor. We covered off on Ward layouts, handovers, abbreviations, medications, conducted a simulated spirometry and discussed the expectation of managing our tool books and work hours. It was a informative and well structured morning, finished off with a spot of morning tea and a coffee, I felt good when I was introduced to the staff I would be working with for the day.

The ward staff where great, professional, well read, and hard working. The Wardsman had just completed his Assistant In Nursing (AIN) training and was filling that role for the day, which was a great help. The RN on duty for the Medical Ward was actually the Nurse Unit Manager (NUM) and her only offsider was one EN. This was going to make life interesting. I managed to sneak in an early Subcutaneous Injection while I still had the preceptor, and an insulin injection when the RN was available. Without the RN readily available doing any Medication Rounds was going to be difficult.

I assisted with cares, made beds, organised files, wrote notes, saw to patients needs, and generally completed the caring side of the nursing job. I had the opportunity to witness a Fleet Enema, preparation for surgery, completed a series of observations and shared a laugh with several of the patients as I went about my business.

I initially felt anxious as I arrived in the morning, by morning tea I was beginning to calm down as I had more information to go off, but lunchtime I was firing on all cylinders, but felt like I was driving around with the handbrake on as I didn’t have the supervision I needed to complete the tasks that I have been trained to do, and by the time I finished my shift I was ready to leave, debrief, reflect on practices and get ready for another day tomorrow.

I know days like today will happen, I know that staffing in Nursing isn’t always perfect, I know that sometimes I will be the only one available to do the job. But today didn’t need to be that day. I am not registered, I am not qualified and I don’t have the Scope to be able to do the things I know needed to be done. Hopefully tomorrow we will have the staff to be able to take the handbrake off and kick some goals.

Looking forward to another day tomorrow, Maintain the Rage,

Luke Sondergeld

Day 1

Day 1 saw us all complete the Mandatory Training for the facility with a number of other staff. The day ran for approximately 9 ½ hours and covered everything from Emergency situations, CPR, Manual Handling, Infection Control, Aggressive Behaviour Management, Electrical Safety, WH&S and an overview of Company, which included a brief talk from the Facility CEO.

Though the day may not have been clinically interesting, as most of the material was fairly standard, although good for a refresher, it was interesting to hear about the company, its values and its culture. The company has a great culture of supported, safe, client centred care. They believe in their employees and treasure their skills, experiences and opinions. The policies and procedures of the facility are often sent out to the staff to ask for feedback, input and commentary. It serves any workplace well to have input from the people who are actually using the polices to test them first.

From day one the facility has set an excellent tone for professionalism, courtesy, input, support, and mentorship. All of these values and ideals are ones that I not only appreciate, but attempt to emulate as a leader, mentor and employee.

My previous apprehensive feelings have been mostly alleviated by the attitudes of the staff and their attitudes towards education and students. I look forward to my coming eight shifts in the Medical ward, and the lessons that will be learnt.

Until tomorrow, Maintain the Rage

Luke Sondergeld

Placement Rage

As regular readers will know I am coming to the end of my Diploma of Nursing studies, which culminates with a five week Acute Care placement, totally some 200 hours. As I did with my Aged Care placement and my Community Care placement, I will be documenting my thoughts, interactions and reflections on my experience. Unlike my last two placements, I will not be summarising after the fact, but in fact giving a daily summary of experiences, emotions and lessons learnt.

Placement Rage 1

Current Thoughts

I am looking forward to putting my accumulated knowledge to use, I am looking forward to the challenge that lies ahead. But, I would be lying if I didn’t say I was slightly apprehensive. I hope I never get to the day where I feel like I know enough, if you don’t think you know enough you will keep asking questions. I am not concerned with my clinical skills, and I am looking forward to learning and applying new ones.

I want to excel, which brings with it a certain level of apprehension as D-Day approaches, doubt creeps in and you begin to wonder if you are going to be good enough. If any of my class mates are reading this, they will be getting ready to echo back the same thing i have been saying to them for months, You will be fine, you know what you are doing, just breath, relax and dive in. And I have been reminding myself of these words, and the sense of irony certainly isn’t lost on me either.

The first day will set the tempo for the whole placement, Orientation Day. We are meeting up at a facility outside of the hospital to be inducted, trained and tested to ensure we are up to scratch before we hit the floor. With previous orientation sessions, the information was simple enough with the focus being on manual handling and general safety. This time however we will be conducting more complicated procedures, delivering medications and monitoring patients who are in a far less stable condition. But as my old Chief Bosun used to tell me, or rather yell at me, Pressure Makes Diamonds.

Placement Rage 2

Blogging Timetable

So the nitty gritty. I will be writing my daily reflection almost as soon as I get home. Therefore if I was to publish as soon as I wrote them, the posts would come out at all varying times, and no one would be able to keep up. So instead I will be releasing the posts the morning after my shift. That will mean the blog posts for the week will be published as;

  • Monday’s at 0600 (AEST) will be normal Maintain the Rage posts
  • Tuesday’s through Saturday’s at 0600 (AEST) will be Acute Care Reflections from the day previous
  • Sunday’s will remain the Sabbath and there will be no new posts

Placement Rage 3I thank everyone for their support of Maintain the Rage thus far, and I thank everyone for their words of encouragement going forward not only with my placement, but my Nursing Career in general.

Maintain The Rage

Luke Sondergeld

Five Community Care Reflections

To follow on from the Reflections of Aged Care and in the interest of continued Reflection so I can Maintain the Rage the following are lessons that I have learnt while on my Community Placement for my Diploma of Nursing. The lessons and revelations that I came to during my placement were; Community Care is not a lesser form of care, Discharge from Hospital doesn’t mean Healthy, Funding is a speed bump not a road block, D is for Danger, a little care goes a long way.

Community Care is not a lesser form of Care

After spending a week in the community setting I very quickly realised, it’s not a lesser form of care, less equiped or less skilled, if anything I found the opposite. The organisation I placed with had two Nurse Practitioners on staff, a myriad of Clinical Nurses and Registered nurses, and an Assistant in Nursing who ran the stores and supply chain. This was a well oiled machine of Healthcare. They were all completely professional, top of their game and the most caring people I think I have met on my journey so far. They work diligently to provide the best level of care they can, and if they can’t, they find someone who can. They didn’t know the meaning of the phrase ‘Too Hard’.  It completely changed my perception of what community care was, which I will admit, wasn’t a very positive one. I alway pictured nurses with a bag of observation equipment, some simple dressings and a box of drugs going from clients home to clients home dealing with  the Elderly and Disabled because they couldn’t make it to the General Practitioners. I could not have been more wrong. This particular organisation ran a clinic in the CBD, an after hours service, visits to the aged care facilities, at home palliation, home delivered clinical services and intra venous antibiotic therapy in the home. Nothing short of a real Hospital in the Home.

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Discharge from Hospital doesn’t mean Healthy

I also learnt that just because someone is released from Hospital that doesn’t mean they are on the mend, they are simply stable and well enough to be at home. This is the sad state of affairs in most countries, where the need for hospital beds is pushing quicker and quicker turn around times. Hospital beds are also becoming cost prohibitive, with the average night stay in Australia costing over $1,800. This has spurred the community health sector into overdrive, the need for advanced clinical skills in the home and community environment is at an all time high. With more people being discharged early, or avoiding hospital and seeking alternative arrangements. That’s were services like the one I conducted my placement with really come to the forefront. We as citizens of our respective countries need to be aware of this, as fathers, mothers, brother, sisters, and children of someone who may be discharged from hospital one day, we need to be aware of what services are available, and what help can be sought. We also need to be aware that the instructions that are given to you on discharge are there to, hopefully, keep you out of hospital. So do yourselves a big favour, especially those who are heading into healthcare, and learn what community services are available and what they can do for your patients on discharge.

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Funding is a Speed Bump not a Road Block

John Kander wrote a song for for his 1966 production Cabaret  which said “Money makes the World go Round”, and unfortunately it does. Healthcare is driven by two things, firstly patients needs, secondly how much those needs cost. Community care in Australia is funded either by the Government or Private Enterprise, and the private enterprises are usually not for profit organisations who receive funding from the Government. These agencies receive a certain amount of money per patient depending on complexity, time needed and a swag of other criteria. These criteria then govern how much the organisation receives to run that service, and what boundaries the organisation has to stay in, so as not to step outside of their appointed jurisdiction. This however does not stop the services from providing the care to the patient. What tends to occur is the service will refer to another community care organisation that has the jurisdiction to cover what is required. As far as the patient is concerned they still receive the right treatment, and the healthcare system get a smiley face sticker for doing the right thing, its a win win.

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D is for Danger

As anyone who has completed their first aid certificate in the past can tell you there is the the pneumonic of  DRS ABCD, where the first D is for Danger, to both the casualty and yourself, community care is a lot like that. Before entering someones home for the first time a risk assessment is conducted, this covers everything from number of people in the house, to pets, to access to the inside, to lighting, everything. The community nurse also has the right to arrive at a patients home and not enter and simply drive away if they believe there is a real threat to their safety, like the 75 kg hungry Rottweiler thats sitting in the front yard. This is paramount for the community nurse, because if they enter the property and the Rottweiler decides they’re lunch, you now have two patients at the residence not one. This lesson can be carried into the acute setting as well, if you have a belligerent patient who won’t settle and is throwing bed pans, grab a mate and tackle the room (not the patient) together.

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A little care goes a Long way

The short amount of time you get with each patient in their home doesn’t leave much room for error, but by providing a little care to the patients in the time you do see them can lift their spirits and help with recovery. Human contact, social activity and conversation are all great ways of battling depression, anxiety and promote good health. The simple act of being kind and caring during your visit could be enough for a patient to see the light at the end of the tunnel and really focus on their recovery, not their condition. Even in community palliation, the difference between openly and compassionately communicating with the client, and always walking on egg shells, can be the difference between what is considered a good death and a bad one. So in all walks of your health care life, care a little, share a little and take the time to be with the patient, not the task.

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My community care placement has taught me a lot, I made a swag of new professional contacts, saw first hand what the services can do for patients, learnt a lot of clinical skills and developed the ones I already had. Do you have a lesson learnt from one of your placements? Do you, or have you had a friend or family member receive care from a community health organisation? If so comment below, if you would like to share your story head to our Connect page so we can share it with everyone. Don’t forget to subscribe to receive email updates of new articles.

Five Aged Care Reflections

With my Community Care Placement beginning tomorrow I have been considering the lessons I leant from my Aged Care Placement I completed at the end of 2016. The placement was nothing like I had anticipated, I pictured the stereotypical residence scenario where most of the residents where mobile, ate in a large dining hall, played canasta for a large portion of the morning and slept away the afternoon, before retuning to the dining hall for an early evening meal. But this was not the case.

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Some ideas are formulated early

1.  Its their home you are just a visitor

The trap some young, inexperienced not necessarily just age young, Nurses and caring staff fall into is that you are at work, a building in which you arrive to every day, clock on, complete a series of tasks, clock off and go home. What you should remember is you are entering someones home, this is where they spend all their time, it’s not a dining hall it’s their dining room, it’s not a common room it’s their lounge room, and it’s not just the room their bed is in, that’s their bedroom, their sanctuary. To that end, you are not an employee who has the right to barge in and do what needs to be done, you are a guest in their home and need to act as such. Tasks should only be completed when they are fully explained, permission is given and in a manner that the resident/client/patient is comfortable with.

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Home Sweet Home

2.  Residents are People and not Tasks

This may seem like something obvious but when you get under the pump and time is short, the task that needs to be completed can seem to be the priority.  As previously mentioned, you are entering the residents home. Picture for a moment a stranger walking into your home; briefly introducing themselves, making your bed, demanding you get up and have a shower, dressing you hurriedly, giving you a small cup full of unknown colourful pills and demanding that you take them.  This is, unfortunately, how some residents are treated. Thankfully the placement I had, I didn’t see anything remotely like this behaviour, but there were times when some tasks where pushed with less than complete consideration given to the resident. So remember you are there to care for the resident/client/patient not complete a series of tasks, take the time to care.

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Task Task Task

3.  Refusal isn’t personal

As Nurses we are taught that residents/clients/patients have the right to refuse treatment, medication or procedures, this also extends to cares, showers, getting dressed and even getting out of bed. How many times have you woken up and just thought “I am not getting out of my pyjamas today, I am sitting on the couch, eating ice cream and watching “Sliding Doors”. This situation is no different for those in your care, they have the right to refuse anything, even having their cares completed by someone who isn’t you.  As a Male I had to be prepared for most of my female residents to refuse to have their cares completed by me. Thankfully this didn’t happen too often, but I did have one resident who absolutely refused to even have me in the room at all, it took nearly two weeks for her to get used to the fact that I was there to assist and allow me into the room, she did however always continue to refuse for me to shower her, dress her or in any way see her in a a state of undress, which is completely understandable. Refusal isn’t personal and as such shouldn’t be taken to heart, just discuss alternatives with your supervisor and move on.

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It’s not personal

4.  You can’t disconnect completely

We are all human, and as such we all develop some degree of human attachment. We are taught to be caring, and supportive, but not to be overly involved. Working in an Aged Care facility I had prepared myself for the inevitable reality of the environment. I am normally quite astute at separating myself from emotional attachments unless it’s necessary, like relationships, friendships and the like. I thought I was doing a great job of it too, I was still caring and supportive of the residents, I was compassionate to their needs, but wasn’t attached in a way that left me vulnerable. Until I met ‘Dave’ (not real name), Dave was a palliative patient who had served many years in a volunteer capacity, his children where only able to visit briefly every week, and he constantly questioned why he was still alive. I endeavoured to make him as comfortable as humanly possible, make sure that his every need was met, but inevitably he passed away a couple of weeks later.  It hit me harder that I expected. Though I was glad that he now had the release he was so desperate for, I still felt saddened by his passing, I knew this world had lost someone who truly cared about others, and placed them above himself. It is perfectly normal to feel saddened, but don’t let it consume you, often there is still plenty of work to be done, and many other residents/clients/patients who need your care as well.

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Don’t let is consume you

5.  Don’t forget to Care for yourself

Anyone who has flown before has been told to “Ensure you have secure your oxygen before helping others”, this extends to the care environment as well, you need to care for yourself before you care for others. If you have cheap, unsupportive shoes, you will get sore feet after standing on them for 8 hours. If you don’t eat properly during the day, you will get tired, lethargic and unwell. Here are a few things to consider to help you help yourself;

  1. Buy good supportive shoes, they may cost over $150 but will save your calves by lunchtime,
  2. Remember to actually stop and eat, we tend to be consumed by tasks and time runs away from us, plan to have a small break twice a day and a longer break for lunch. All this assumes your workplace allows this,
  3. Eat fruit, nuts, lean proteins and complex carbohydrates. Try and avoid the tendency to grab a quick slice of cake, handful of chocolates or other quick snack,
  4. Rehydrate, Rehydrate, Rehydrate! Remember to drink plenty of water during the day. It is not unusual to walk over 20,000 steps in a shift, couple that with the dry air conditioning of most facilities and you will quickly realise that your intake will have to be higher than normal, and
  5. Actually go to the bathroom, it only takes a minute. With all that water, and normal body processes you will need to go to the bathroom. Actually go, there are many health problems that can develop from urine retention over time, take the time to relieve yourself.
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Help yourself so you can help others

This is in no way all of the lessons learnt during my placements, and certainly not an exhaustive list of cares for yourself, but they are some of the most important. I am thoroughly looking forward to the next opportunity to serve the community and those in need. I anticipate there are going to be an inexhaustible list of new lessons learnt from this next placement, but as one of my Commanding Officers once told me “The day you stop learning is the day you become dangerous”, it was true then and remains true today.

Do you have lessons learnt from your nursing experiences? Do you have secret cares that you can’t go a day without? Write them in the comment section below, after all community is key to success.