With the support from nursing colleagues at Imperial College Healthcare NHS Trust, London, the following scenario explores the learning experiences of a second-year student nurse on placement in a haematology ward.
The practice environment
Ward B is a 29 bedded haematology ward made up of four bedded bays and single rooms. Each bay has a maximum of four patients. Each person is receiving support and care for different haematology conditions.
This scenario focuses on the learning of second-year adult student nurse Naomi on a night shift during the second week of a six-week placement. In particular, Naomi’s learning when caring for one person, Joseph, who lives with sickle cell disease and has been admitted to hospital with a veno-occlusive crisis (VOC) and an ulcer on his ankle.
On the night shift with Naomi is her practice supervisor, Karen, two other registered nurses, Jerome and Angela and two healthcare assistants Hazel and Simon. Naomi also has a named practice assessor, Isobel, who was not on duty.
Learning objectives and priorities for Naomi
Naomi agreed her learning objectives with Isobel in her first week of placement. She has already discussed these with Karen and together they have decided that the focus for the night shifts will be:
- Developing an increased awareness and understanding of sleep hygiene.
- Safe and effective administration and optimisation of medicines, specifically analgesia.
- To observe and assess people’s comfort and pain levels and their rest and sleep patterns. Nursing care for people with sickle cell disease, and in particular acute VOC.
- Naomi will be responsible for providing care for three people plus an empty bed space in Bay 1 with Karen’s support.
People in Naomi’s care
Martin is 42 years old and was admitted for chemotherapy for haematology cancer.
Joseph is 36 years old; he has sickle cell disease. He has had multiple hospital admissions due to acute VOC. He's currently experiencing high levels of pain and has an ulcer on his ankle. He's also having some respiratory problems.
George is 51 years old and was admitted for investigation and management of multiple bruises on his arms and legs and his gums are bleeding.
The fourth bed is currently empty and the ward is expecting a person to be admitted in the morning for investigations for a haematology condition.
Putting the Proficiencies into Practice
The Standards of proficiency for registered nurses list the knowledge, skills and behaviours that every nurse needs to know and be able to do, by the time they register with us.
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.
Using the platforms as a guide, the following provides some examples of what Naomi was able to learn and demonstrate in line with the standards of proficiency during this night shift.
What Naomi did:
After being supervised administering prescribed medicines, Naomi checked that all four patients were okay and turned the main light off, leaving just the night lamps on.As Joseph was playing music from his tablet, Naomi asked him to keep the volume down to avoid interfering with anyone else’s sleep.
A few minutes later, Martin, informed her that he was unable to sleep as Joseph’s music was too loud. Naomi approached Joseph and he shouted back: “Don’t you know that I am in pain? Music is my distraction; you don’t understand what I am going through!”
Naomi recognised that Joseph was in severe pain and that while listening to music provided important distraction for him, she also knew that this was disturbing other people. Naomi sat with Joseph listened to and acknowledged his experience of pain.
She listened carefully as he explained that he has become accustomed to people not understanding his pain and not believing him. He said this was particularly the case when being cared for outside of the haematology centre. He felt people did not understand the disease.
Joseph was clearly upset and he expressed his frustration. They discussed music that they both enjoyed and Naomi asked where his headphones were. The headphones needed charging and he did not have a charger.
Naomi remembered that there were spare chargers in the nurse’s station drawer that Joseph could borrow. She went to see if she could find one that would work and, in the meantime, lent him her headphones. Naomi assessed Joseph’s pain and spoke to Karen to see if more analgesia could be administered and if this could be reviewed.
Once Joseph had some headphones, Naomi went to speak with Martin and apologised for the disruption and thanked him for his understanding.
What this demonstrated:
Naomi reflected on this encounter and recognised, that, she found Joseph’s behaviour difficult to understand as it was disturbing Martin. She had to remind herself that she has a responsibility to all the people in her care and that she needed to provide each of them with person-centred care. Naomi realised this was not always easy as in this situation there were conflicting needs.
She reflected on her ability to demonstrate non-discriminatory, person-centred, professional care at all times and saw that this experience had challenged her perceptions and approach. She considered how angry Joseph had been and tried to empathise with his experiences as a person living with sickle cell disease and how these experiences might have shaped his life.
What Naomi did:
Naomi was able to discuss and describe to Karen that the people in her care have compromised immunity either due to their diagnosis and or due to the treatment they were receiving. She was able to explain to Karen how people with sickle cell disease are at higher risk of infections and sepsis.
Later, on the following morning, Naomi noticed that Joseph had been given some leaflets about healthy eating and hydration for people with sickle cell disease. She asked him how he felt about that.
She focused on listening to him rather than giving information as she realised that Joseph understood more about living with sickle cell disease than she did. Joseph was motivated to be as healthy as possible, took his diet seriously and was pleased to discuss this with Naomi.
During the conversation Joseph mentioned that he was aware that people with sickle cell disease can often feel marginalised and that he believed that there was not enough known or new research about the disease compared to diseases that affect white people.
Before starting this placement Naomi knew little about this disease, so was able to relate to what Joseph was saying, she was unaware of different genetic disorders and any associated health inequalities that might relate to these. She decided she needed to know more about this.
What this demonstrated:
Naomi went and found out more about sickle cell disease and other genetic disorders, she was able to demonstrate knowledge of epidemiology, demography, genomics and the wider determinants of health, illness and wellbeing and apply this to an understanding of global patterns of health and wellbeing outcomes.
She was also able to understand the factors that may lead to inequalities in health outcomes. Naomi recognised that she had been able to communicate and empathise with Joseph, she also realised he knew more about his condition than she did and so used a strength-based approach to support him.
What Naomi did:
Joseph has an ulcer on his ankle that was very painful. This wound was producing a lot of fluid and so his dressing needed to be changed. Naomi was surprised to see a younger person with a leg ulcer as, during her previous experience, working with a community nurse she had only seen leg ulcers in older people.
Naomi asked Karen why this had happened, Karen suggested she needs to think about what she knows about anatomy and physiology, and look at the causes of wounds and the different stages of the healing process. In this situation in particular, to consider circulation, and how this can be affected by sickle cell disease.
Joseph had bought dressings from the chemist as he “hadn’t time to spend all day in clinics”. Naomi assessed the wound with an understanding of erythema in people with black skin, noting that redness may not be seen and to observe instead for tight shiny skin indicating swelling. Joseph agreed to let Naomi show him how to clean the wound and they discussed which was the best dressing to use. Joseph still wanted to do this himself but agreed to visit the practice nurse at his local GP so they could review how well it was healing.
Karen observed Naomi assessing and re-dressing the wound using an aseptic technique and recorded her assessment of this skill in the practice assessment document.
What this demonstrated:
Naomi was able to work through her knowledge and understanding of anatomy, physiology and body systems and link this with her previous experience of caring for people with leg ulcers. She was then able to apply this knowledge to Joseph’s situation and considered that sickled red blood cells might be causing obstruction to the small blood vessels, reducing the oxygen supply to the skin and contributing to venous incompetence.
Naomi was able to demonstrate she processed this information, taking into account Joseph’s ethnicity and his personal needs and preferences. Combined these all informed her assessment and contributed towards his person-centred plan of care.
What Naomi did:
Naomi monitored Joseph for any signs of deterioration in his physical health regularly throughout the night shift. This included respiratory rate and oxygen saturation as Naomi was aware of the risk of pulmonary complications with sickle cell disease. As Joseph had black skin, she looked at his tongue and oral mucosa rather than general skin colour. His tongue looked a blue grey colour this would indicate high levels of deoxygenated haemoglobin. She also noticed his pale conjunctival and palmar crease pallor, further indicating reduced oxyhaemoglobin levels.
Naomi sought advice from Karen about waking Joseph for regular and close monitoring of physiological measurements and calculation of National Early Warning Score (NEWS2). They had a discussion about the need for sleep and rest to assist the healing process. Naomi discussed the reasons for the regular observations with Joseph. They agreed to let him sleep, but that she might need to wake him should she feel it was necessary and Joseph agreed that this was the right thing to do. It was decided that, due to Joseph’s condition, the observations should continue regularly, every hour, through the night. Naomi did this as quietly and calmly as possible and only inspecting the oral mucosa if she had concerns.
As Joseph had previously found that an opioid patient-controlled analgesia to be effective this was prescribed and commenced. Joseph was familiar with the device used and found it helpful. Naomi continually observed Joseph for adverse effects of opioid medication. She discussed with Karen the short and long-term effects of opioid use and how people are using opioid medication can become tolerant of it, which means requiring higher doses to achieve pain relief. They also talked about other effects including respiratory depression, behaviour changes, constipation and sedation.
Naomi informed Joseph that she would be monitoring his pain hourly throughout the night. She reflected on his previous comments about not being believed and discussed this with Karen. Together they discussed the relevant anatomy and physiology associated with an acute veno-occlusive crisis and why this was so painful. They also discussed different methods of pain relief, for example, social prescribing, cognitive behavioural therapy. They decided that they will ask his named nurse on the day shift to discuss the different options available to him.
Karen and Naomi discussed how they would respond to any deterioration in Joseph’s condition specifically how they were observing for acute chest syndrome. As part of this preparation together they completed the night shift checking the emergency equipment. This was an opportunity for Naomi to learn more about emergency equipment and the procedures for managing medical emergencies on Ward B. In addition, Naomi checked the oxygen and suction equipment by the vacant bed space in preparation for the elective admission in the morning.
What this demonstrated:
Naomi showed she has the underpinning knowledge to respond proactively to signs of deterioration. She also demonstrated that she had knowledge of the use of opioid medication and the ability to recognise side effects and adverse reactions.
Naomi showed that she was developing an understanding of the complexities of pain management in people with sickle cell disease and what interventions might be appropriate to support people’s individual care plans. In addition, she showed an understanding of acute chest syndrome and how this is associated with sickle cell disease.
What Naomi did:
During the night shift Naomi managed the nursing care of the people in her care with Karen’s support. The people in the bay had different diagnoses, treatments and therefore different needs and agreed care plans:
Martin has a cancer diagnosis and was receiving chemotherapy. The main consideration there was around infection prevention and control and close monitoring of physiological measurements and calculation of National Early Warning Score (NEWS2).
George was waiting for the outcome of preliminary tests to confirm a diagnosis. The priority for George was to provide information around his remaining investigations and to listen to any concerns he may have.
Joseph required urgent pain relief medications, ongoing reassessment and evaluation through close monitoring and to prevent respiratory deterioration.
Naomi considered all these factors when planning the care and responding to their ongoing needs during the shift. During the night Naomi contributed to the electronic patient records documenting the agreed care given.
In the morning Naomi provided a comprehensive handed over for the three people. Karen did not need to prompt and commended Naomi in achieving this and said that she will let Isobel her practice assessor, know.
What this demonstrated:
With Karen’s support and supervision, Naomi safely and effectively managed the care of the people in the assigned bay. She appropriately involved them in decisions and prioritised their care needs, and was able to effectively access the appropriate digital technology to record this.
What Naomi did:
Karen and Naomi took the opportunity to reflect on the incident earlier in the night when Joseph became angry. They both recognised that this incident could have escalated and compromised the safety of other people in the bay including staff. Karen recorded this incident as a ‘near miss’.
Karen commented that she had experienced previous issues when patients had been unable to charge a mobile phone leading to frustration and angry outbursts.
These were audited and documented and had led to a service improvement project where the ward kept a stock of chargers that could be loaned. Naomi reflected on the importance of recording near misses and how audits can lead to changes that positively affect people’s experiences and safety.
What this demonstrated:
Naomi showed an understanding of how the identification, reporting and critical reflection of near misses can lead to learning and influence of future practice and justify improvements.
What Naomi did:
Naomi spent time listening to Joseph, when he was not sleeping, about his experiences with sickle cell disease. She realised he may need complex person-centred health care for the rest of his life, and that his experiences of living with sickle cell disease would be unique and different to that of others with the same condition.
She also recognised that it was important to Joseph that he was able to live his life in a way that mattered to him, without any unnecessary hospital admissions or clinic visits. This led to a reflection on how people with long term conditions are supported to do this, and the importance that they remain in control of their care and how their ongoing feedback and experiences are listened to.
She decided to find out more about community-based services for sickle cell disease and what may be helpful for Joseph. Karen recommended that Naomi make contact with the haematology specialist nurse at the hospital to discuss this further. On Joseph’s recommendation Naomi also viewed the resources on the website of the Sickle Cell Society which is a charity in the UK that supports and represents people affected by this disorder to improve their quality of life.
What this demonstrated:
By caring for Joseph, Naomi learnt about the life long effects of and living with sickle cell disease. She also developed an awareness of how people with long term conditions are supported to maintain optimal independence and avoid unnecessary interventions and disruptions to their life.
Test your understanding
Questions to prompt reflection and discussion
- Sickle cell disease is particularly common in people with an African or Caribbean family background; what opportunities are there for students to care for and learn about people with long term conditions that may be affected by ethnicity? (aligned to proficiencies 2.2, 2.3; and 2.5).
- Naomi’s used skills to assess wounds and cyanosis for a person with black skin. What opportunities do students have to learn about clinical assessments and how do they differ depending on skin tone. (aligned to proficiencies 3.2 and 3.5).
- Naomi will have an opportunity to learn about genetics and genomics associated with sickle cell disease during this practice experience. Is there opportunity for students to have this experience in your place of work? (aligned to proficiency 2.2).
- Naomi’s encounter with Joseph was documented as a ‘near miss’. How do students learn from incidents/near misses in your area of practice? (aligned to proficiencies 6. 8 and 6.9).
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.
