This scenario focuses on the learning that Saima undertook while on a shift during her third week of a ten-week practice learning experience on Ward A which is a surgical ward.
Saima is starting to feel a little more confident on the ward after being there for nearly three weeks
Her key objectives during this placement are: to develop her knowledge and skills around person-centred patient assessment, medicines optimisation and administration and safeguarding in the acute hospital setting. Her previous practice learning environments included a care home, a medical ward and a health centre.
Saima also wants to develop patient management skills. She’s currently being supervised to manage the care of two patients during her shift, and her practice assessor has set her an objective of leading the care of four patients in a bay by the end of this placement.
Saima is joined on this shift by:
- Emma: a first-year student nurse
- Darren: a third-year student nurse (who will be co-ordinating the bay and will be Saima’s practice supervisor under the supervision of Grace)
- Colin: a Health Care Assistant (HCA), also allocated to support the care of people in the bay
- Grace: the RN who is the practice supervisor to Darren, Emma and Saima
Saima also has a named practice assessor who is different to her practice supervisor and she is working in another bay on this shift.
Planning for her shift
Saima is familiar with the patients as she was supporting their care the day before. Under the supervision of Grace, Darren asked what her learning objectives were for this practice experience so that he could appropriately delegate the care of the patients. As Saima had cared for Annie and Elouise the day before and to ensure continuity of care the same patient allocation was agreed.
Saima's patients
- Female aged 93 and normally lives in a residential care home; her son and daughter-in-law live locally.
- Admitted with pyrexia, coughing, trouble swallowing, and shortness of breath, confusion, loss of appetite, weight loss, rapid heartbeat, and bluish skin around her mouth and finger tips, and sputum that is pink. She has an initial diagnosis of aspiration pneumonia.
- Various tests and investigations have been requested and carried out including blood tests, sputum culture, urine sample and a chest x-ray.
- Intravenous (IV) fluids, IV antibiotics, oxygen therapy and steroids have been prescribed and have been administered over the last 24 hours.
- Annie is mildly confused.
- There were no medical beds available on admission and she may be moved later in the day.
- Female aged 19 years.
- Elouise has a two-year-old daughter (Riley) who she’s very concerned about as the last few months have been disruptive. Elouise lives with Riley in bed and breakfast (B&B) accommodation awaiting local authority housing. She moved to the B&B from a woman’s refuge having recently left an abusive relationship. Riley is currently being looked after by a trusted friend as Elouise is currently estranged from her family.
- She had an appendectomy performed two days ago where an abscess was found, now she has an elevated temperature of 38ºC and her wound is looking inflamed. IV antibiotics have been prescribed and administered over the last 48 hours.
Learning objectives and priorities for Saima
Saima identified her learning objectives with Darren and Grace and gave an outline plan of care that would meet both Annie and Elouise’s needs. She struggled to provide a detailed level of understanding of their admissions, the physical, mental and social aspects of their health and care in terms of their current pathophysiology. Grace recommended to Darren that Saima should consider these areas during her shift and feedback later in the day. Saima was keen to learn more about medicines optimisation and administration. Darren suggested that post-operative medicines including analgesia, IV fluids and antibiotics should be the area she focuses on and their impact on Elouise following surgery.
After receiving a handover from the night staff, Saima outlined her priorities and planned to start by introducing herself to Annie and Elouise. She wanted to make sure she understood what their needs were, their plan of care, that they were comfortable and to familiarise herself with their physiological observations and medication charts, and ensure she was aware of when these were next due.
Saima recognised the need to actively listen to and find out what was important to them. She acknowledged that although they have different needs, they both required sensitivity in her approach. She planned to assess Elouise first as she was still recovering from surgery. Saima established that Annie would require more time and assistance in her care.
Moving and handing, patient safety and safeguarding are part of Saima’s learning objectives for this experience. Darren recommended that she reads the relevant local policies and then discusses how these apply to Annie and Elouise. Saima and Colin were working together as Annie’s moving and handling assessment indicated that two people are needed for moving her from the bed to a chair. Saima was also able to delegate some aspects of Annie and Elouise’s care to Colin, for example, administering and documentation of oral fluids.
Putting the proficiencies into practice
The Standards of proficiency for registered nurses state the knowledge, skills and behaviours that every nurse must have by the end of their programme and to join the register.
The standards are set out in seven sections called 'platforms'.
In addition, there are two annexes to the platforms that list the communication and relationship management skills nurses must have, and the nursing procedures they must be able to do when they join our register.
Through some examples see how Saima was able to demonstrate certain learning outcomes of these proficiencies through this practice experience.
What Saima did
Saima re-introduced herself to Annie and Elouise and made sure she was familiar with their needs and agreed care plans.
She recognised that Annie required a considerable amount of assistance. Annie had referrals to the speech and language therapist and to the hospital social worker and Saima needed to follow these up and find out more about the next steps. Saima took guidance and support from Darren acting as co-ordinator and Grace overseeing his supervision regarding how to do this.
Seeing that Annie was becoming more distressed and confused, Saima considered the potential reasons for this, drawing on her knowledge and experiences. She provided support and time for Annie by speaking calmly, using simple language and spent time asking open questions and actively listened to her concerns and needs.
Saima knew that she normally lives in a residential care home, and noted that her overall nursing care needs seemed significant. Saima wanted to know if Annie had been confused for some time or if this was linked to her aspiration pneumonia diagnosis. Saima spoke to the nurse at the care home and it became clear that Annie had progressively become more disorientated and confused in recent days. Saima decided to speak to her practice supervisor about this.
During the multidisciplinary round and review Saima felt she now knew Annie and Elouise and the care that they required well enough to participate. She had not felt confident to do this before.
Saima discussed Elouise with Darren, including the relevant anatomy and physiology that led to her condition. This supported Darren’s confidence that Saima understood the surgery that Elouise had received. Darren and Saima discussed what an abscess is, and the best practice evidence to support wound care and healing. Saima was able to explain and reassure Elouise about the wound abscess when she became distressed that the dressing was soiled with exudate and what the plan of care would be.
Annie required regular IV medication and Saima ensured that she was aware of when these were next due and observed the preparation and administration of these medicines. Both Annie and Elouise had IV fluids administered and Saima made sure that this was clearly documented on their respective fluid balance charts.
Saima took some time with her supervisor to discuss the shift and her reflections on her own learning objectives in relation to the care delivered to both Annie and Elouise.
What this demonstrated
Saima demonstrated the need to base all decisions about person centred care and interventions on people’s needs and preferences. Through her focused communication Saima was able to manage and maintain appropriate therapeutic relationships with both Annie and Elouise. Saima demonstrated the ability to keep clear and accurate documentation. She drew on her knowledge and experiences to contribute effectively to the multidisciplinary team discussions.
What Saima did
Saima noticed that Elouise was feeling unwell and Saima assessed and checked her vital signs, which showed she had an elevated temperature of 38ºC. Saima spoke to her supervisor and the doctor who both reviewed her wound. Saima was asked to take a wound swab, something she had not done before but was able to do so using an aseptic technique with Grace’s guidance and supervision.
Saima noted that both Annie and Elouise were receiving antibiotics. She spent some time reading the hospital’s antimicrobial guidance and reflected on the use of antibiotics for acute medical conditions for Annie and as part of the post-surgical plan of care for Elouise. She discussed with Darren the role of the registered nurse in antimicrobial stewardship and had a conversation with the ward pharmacist about the review date for these medicines.
Saima observed correct infection control measures that applied to both patients including appropriate use of personal protective equipment (PPE), asepsis and correct waste disposal.
What this demonstrated
Saima recognised the need to protect health through principles of infection prevention for patients and staff.
This included her responsibility to wear the appropriate PPE to create a barrier between herself and any infectious agents. She was also aware of the underlying principles of managing healthcare waste and understood the wider consideration of antibiotic resistance in relation to public health.
What Saima did
Saima used a range of approaches to re-assess the care of both Annie and Elouise, including their history, mental, cognitive and physical health needs assessment, measuring vital signs and recognising the need for timely and planned interventions and care.
While listening to Elouise, who said that she was scared of her former partner and was worried about her daughter, Saima noticed burn marks on her forearms.
When talking with Elouise and helping her wash, Saima noted further burn marks elsewhere on her skin and sensitively asked what the marks were and how she got them. Elouise was reluctant to respond to Saima and changed the subject.
Saima decided to discuss her concerns with her Darren who also had a conversation with Elouise. They both felt the safeguarding team needed to be made aware and discussed this with Elouise who agreed but was visibly scared. Time was given to Elouise to express her fears. Darren then supported Saima and contacted the safeguarding team for advice and the next steps.
Saima was commended by her supervisor on how she was able to look beyond her patients’ initial reason for admission and start to put together the information gathered to provide person-centred care.
What this demonstrated
Saima had limited knowledge about safeguarding issues but knew who to speak to and escalate her concerns to. She recognised that Elouise has wider care needs including safeguarding and had multiple social issues to consider. These care needs were planned respectfully, taking any ethical considerations into account when supporting Elouise to voice what her health, social and wellbeing needs, and preferences were.
What Saima did
Throughout her shift, Saima demonstrated many elements of the proficiencies within this platform and particularly the ability to use knowledge and skills to evaluate the care of people and apply her knowledge of anxiety, confusion, discomfort and pain.
Saima also discussed with Darren the diagnostic tests that had been requested and actions taken around the use of steroids and the selection of IV antibiotics that can be prescribed for people with aspiration pneumonia. Saima provided a good level of understanding of the affect steroids would have on Annie’s breathing/condition and was able to present possible reasons for her current confusion.
Furthermore, she was able to emphasise the need to continue to monitor Annie’s cognitive and mental state to be able to evaluate whether the prescribed medication was being effective or whether further investigations and treatment were needed.
What this demonstrated
Saima showed some understanding of aspiration pneumonia pathophysiology and a clear understanding of applying a person-centred approach to nursing care.
She also demonstrated the ability to process information for evidence-based care. Saima also wanted to understand the reaction of the body’s systems when such aspiration happens, to enable her to provide better support and person-centred care.
What Saima did
Saima lead the care of Annie and Elouise throughout the day, including undertaking regular physiological observations and administering medication at the appropriate times.
With the support of Darren and Grace, Saima felt empowered to prioritise and deliver the care they both needed. She worked within her limitations by asking for support and advice to ensure their safety at all times. She also confidently delegated some aspects of patient care to Colin.
What this demonstrated
With the support of Darren and Grace Saima coordinated their care throughout the shift. She showed an understanding of the importance of team working and collaborative and inclusive decision making.
What Saima did
Saima was required to undertake a series of routine risk assessments, such as skin integrity assessments, nutrition, hydration, moving and handling.
Once completed Saima discussed the outcome of those assessments and planned interventions. In particular, Saima noted that Annie was at risk of developing pressure ulcers. Saima followed the local policies aimed at preventing the development of pressure ulcers, explained to Annie what needed to happen and arranged for the appropriate pressure relieving mattress to be delivered without delay.
In addition, Saima escalated her concerns around Elouise’s social situation promptly acting on what she’d observed and what was disclosed to her.
What this demonstrated
Saima demonstrated an understanding of managing and reporting emerging risks. She recognised Annie’s risk of developing pressure ulcers, and the need to avoid this from happening and that a safeguarding concern surrounding Elouise’s and her daughter’s safety needed wider agency collaboration. Saima knew how to plan, escalate and respond to different concerns in a timely way.
Saima correctly used available patient data and had the confidence to communicate the reasoning behind her actions and decisions and was able to identify the potential next steps.
What Saima did
Neither Annie nor Elouise were ready for discharge. Saima was aware of this, however, she did identify the importance of early preparation and planning for discharge.
Saima built a good rapport, actively listened to both and made sure that they felt comfortable with her and trusted her. She engaged with other members of the multidisciplinary team and gained important information about both patients.
Saima spent time prioritising the care required and was able to safely delegate tasks to Colin the HCA.
What this demonstrated
Saima co-ordinated the person-centred care provided for each. She demonstrated an understanding of mental, cognitive, behavioural, social and physical care needs.
Both patients had different complex needs. Saima showed that she had an understanding of their individual needs and also knew when and how to escalate her concerns.
Saima showed that she had an understanding of the principles and processes involved in facilitating safe discharges. She contacted the wider agency teams that needed to be involved with their support and care and gained essential information relevant to planning their discharge.
Test your understanding
Questions to prompt reflection and discussion
In order for Saima to achieve her objectives in relation to medicines optimisation and understanding of the law around safeguarding identify two proficiencies that Saima still needs to learn and apply and what learning opportunities would you consider might be available for her in your practice area to achieve this?
Examples could be:
Platform Four
4.15 demonstrate knowledge of pharmacology and the ability to recognise the effects of medicines, allergies, drug sensitivities, side effects, contraindications, incompatibilities, adverse reactions, prescribing errors and the impact of polypharmacy and over the counter medication usage.
Learning opportunities /objectives to meet the requirements of this proficiency:
- Medication rounds: Saima should be involved in the administration of medicines for the patients in her care with the objective of leading on the safe administration of medicine for these patients.
- Ward Pharmacist: Saima could spend time with the ward pharmacist with the objective of understanding their role, specifically with reference to how medication reviews are carried out.
In addition, Saima could work towards the following related Annexe A & B skills and procedures:
- Annexe A: 1. Underpinning communication skills for assessing, planning, providing and managing best practice, evidence-based nursing care.
- Annexe B: 11. Procedural competencies required for best practice, evidence-based medicines administration and optimisation.
Platform 3
3.8 understand and apply the relevant laws about mental capacity for the country in which you are practising when making decisions in relation to people who do not have capacity.
Discussion
Saima will meet other people like Annie who may temporarily or permanently lack mental capacity to make decisions for themselves. She should observe and then participate in how to involve people generally and the decision-making process for someone who lacks capacity for a particular situation or care decision.
In addition, Saima could work towards the following related Annexe B skills and procedures:
- Annexe B: 1.1.2 Cognitive health status and wellbeing.
Revalidation
If you are a registered nurse you may wish to use this scenario and your reading as part of your continuing professional development (CPD) for your revalidation.
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