Description

Following receiving confirmation of my placement, I was informed I would be a part of the critical care ward, later updated insights from my Clinical Educator that my position would be within the cardiothoracic unit. My clinical educator was in touch quickly to provide the necessary pre-placement forms to offer access to WIFI, a laptop, an NHS login and pre-reading to complete. Pre-reading tasks were self-directed tasks to research and investigate the theory related to CVR practice, research and clinical procedures. Initially, my main focus was on assessment procedures. However, contacting my clinical supervisor regarding the assessment tools and methods specifically within the ward I would be practising within allowed for specific detail to be given towards the ABCDE assessment method.

Feelings

Having had a drive for Cardio-respiratory (CVR) placement, receiving confirmation for my first placement within this area of my desired field, hospital and ward created feelings of excitement and apprehension. Revolving around feelings of uncertainty towards clinical assessment, due to the nature of pre-placement university learning, where Airway, Breathing and Circulation (A-C) are the main focus of teaching.

Evaluation

And so I felt during the evaluation of my feelings, it best to address this through following further reading around the topic. Using resources provided by the university for self-directed learning (SDL), as well as my independent research using Sheffield Hallam University (SHU) Library Gateway, Chartered Society of Physiotherapy (CSP) resources available online. I felt more settled as following the process of evaluation and following the action of self-directed study.

Conclusions

I started to grow in the theoretical knowledge of the Disability and Exposure aspects, and the A-C aspects taught in my studies. I still felt apprehensive as the particular practical day was a learning curve for me to become aware of weaknesses in critical thinking towards developing hypotheses and using auscultation to guide decision making, alongside interpreting critical values from vital signs.

Action Plans

To best prepare for placement while maximising feelings of excitement and minimising apprehension. I set an action plan to cover the provided pre-reading, create an overview of my learning and practical application in self-directed and supported sessions performed. To best understand the procedures provided by my clinical educator, I have an action plan for my research into the topics, followed by a question list to discuss with my supervisor and clinical educator at a later date to further my learning once able to assess my application of theoretical knowledge during placement responsibilities.

Description

Within cardiothoracic surgery, specific attention is drawn within assessments to the clinical examination of pain control, oxygen delivery system, chest drain used, catheter presence, postoperative complications (pulmonary, cardiovascular, wound, neurological, musculoskeletal, gastrointestinal, renal, and central nervous system complications.), cardiovascular and respiratory status (assessed by checking their heart rate and rhythm, blood pressure, respiratory rate, and oxygen saturation.), ROM and biochemical data (ABGs and chest x-rays) (2)

As per the Resuscitation Guidelines 2021: The ABCDE Approach (3), comprehensive, reliable and valid assessment requires understanding and effective communication of the A-E approach; Using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to assess and treat the patient. During my second day of clinical practice, I was left independently to carry out two ABCDE assessments and supervised the investigation of three patients across day one and day two in practice. During ABCDE assessments, my communication skills were deemed adequate, concise and clear to inform the patient of procedures and align with CSP standards in gathering consent from the patient for assessments, interventions and any plans put into action following. The patient's license/consent is essential for any evaluation and/or intervention that involves touching the patient, asking them to remove/move clothing items, or using any instrument or modality that consists of breaking the skin (4). Patients are now entitled to receive any information they ask to make their own decisions about their treatment (5). Montgomery means that concerning the information and/or advice you give your patients about their physiotherapy management, the default position now is that you must provide ‘what the patient wants to know. This is regardless of your professional opinion and judgment on whether you would usually give the information.

During this learning experience at the end of my first week of clinical experience, I had begun developing a broader understanding of patient requirements based upon CSP and NHS values. Alongside, clinically being challenged to apply the pre-placement learning into practice. Visiting a patient within the Chesterman 3 (CH3) ward (named PL for confidentiality), the importance of being to understand Arterial Blood Gases (ABGs) as part of the A-E assessment was highlighted when observing pre-assessment procedures to assess a NEWS2 score, observation charts, patient documentation and having open-discussion with MDT care-providers on current condition biological, psychological and socially. Following an expected fall from his bike, PL was admitted with an unknown cause, which led to multiple pathologies. PL's main concern was the chronic pain from his ribs, caused by multiple rib fractures. My clinical supervisor noted before assessment that PL's Blood Pressure (BP) was high. Due to this, alongside the high amounts of pain medication he had received just 1/24 before our arrival, adjustments were made based upon contraindications for mobilisation (gait).

Feelings

This experience filled me with a great sense of motivation to understand and interpret data to inform my clinical practice, aligned with best practice guidelines. Driven to provide adequate care through these evidence-based interpretations and interventions, my end of week objectives reflect this.

Evaluation

To align with CSP core standards where ‘there is a systematic, proactive and responsive approach to risk management that follows the organisation’s overall strategy, I decided to place effective and thorough assessment skills as a priority for early placement objectives (6). In this case, that led me to ask my clinical practice educator further questions about how I could best improve my assessment practice and the provision of an assessment documentation template to assist me in note-taking and the A-E assessment process.

Analysis

Through this effective communication with my clinical educator, dedication to further learning through self-directed tasks and research, I learned from the interaction with PL. I provided a thorough A-E assessment on a patient seen later in the day called NM. Before assessing NM, I observed his patient documentation and observational charts and discussed his condition with the relevant nursing staff and occupational therapist. Having learnt the meanings for abbreviated terms of NM's condition earlier in the week (02/06/21) for myocardial infarction (MI), I was able to prepare myself for the assessment independently until having queries regarding mobilisations in the presence of a balloon pump. Discussing this further with my clinical educator provided me with an insight into the depth of clinical reasoning and theoretical knowledge required to deliver a safe and effective service practice aligned with CSP core standards.

Conclusion

The whole scenario was a great learning experience. It made me aware of the importance of a broad understanding of clinical procedures performed outside of Physiotherapy and a deeper awareness of the specific features of cardiothoracic care provision. In attempting to achieve this skill, I will seek to further my learning through case studies and online observation of subjective and objective assessments using the A-E method pre- or post-operatively within cardiothoracic care.

Action Plan

Seeking to continue my professional development, I will continue progressing and assessing my assessment skills as I gain more knowledge and independence to conduct these without supervision. I will also keep a shortlist within my pocket notebook to reduce the likelihood of gaps being left within my A-E assessment procedure or the following documentation of assessments and interventions.

Week One End of Week Review

According to assessment requirements, I have opted to continue using the Gibbs Reflective cycle to reflect on my clinical placement experience. The Gibbs Reflective cycle will guide me through stages of description, feeling, analysis, evaluation, conclusion and an action plan (11). Following my first reflective cycle and week of placement, I believe continuing proactively will allow me to continue developing and growing in my clinical practice and theoretical knowledge.

Goals & Objectives

• To Independently complete and document an A-E Assessment

• Remember and practically apply knowledge of ABG normative values

• Continue to practice communication and reflect using SWOT and Gibbs cycle

Description I

In week 2 of clinical placement, my main focus remains upon developing my theoretical knowledge of underpinning principles surrounding A-E assessment procedures, interventions and effective communication. However, following reflection and progress to my continued professional development, an additional level of detail is given to the method of delivery and ability to adopt NHS core values of patient-centred care while continue to practice observations, assessments, goal setting and outcome measures. During self-directed study using the resources available upon Microsoft Teams from STH I was able to further develop my clinical skills beyond assessment, and begin to clinical apply theoretical knowledge to clinical findings from comprehensive assessments in order to use clinical reasoning prior to intervention delivery. In further reading beyond the case study tasks set, I began reading deeper into a patient called Thomas and his clinical presentations. Previously I had performed an A-E assessment upon Thomas under the supervision of my clinical educator, receiving positive feedback regarding my inclusion of all aspects of the assessment and accurate auscultation interpretation. However when challenged further I was unable to relay this information to generate an accurate hypothesis for potential interventions beyond mobilisation or deep-breathing exercises (DBEs). Independently using SHU Library Gateway and ‘The Physiotherapy Pocketbook: Essential Facts at your Fingertips’, I was able to create a ‘problem list’ for my clinical educator to assess. My learning also led me to research the thoracic procedures commonly performed on patients I had interacted with including VATS, STEMI, Lobectomies and COPD to list a few. This further learning set me up for a successful and productive learning experience the next day when working on clinical placement.

Description II

Following my self-directed and further learning in preparation for clinical placement, I again sat in on the handover meeting procedure, this time able to have an awareness of the majority of terminology and abbreviations used. Furthermore, during the meeting, and my clinical supervisor made intentions for me to complete a full subjective and objective assessment of Thomas, where my supervisor and I agreed I would act independently in all aspects of assessment and intervention other than the auscultation technique, which would be supervised in order to assess my interpretation. Following this independent assessment and documentation of assessment performed, I then assisted in the completion of using an E70 for Nasophargeal Suction through the methods of MI:E, IPPB in partnership with ACBT deep-breathing manual techniques.

Feelings I

Thoracic procedures are considered to involve some of the most painful surgical incisions and are associated with severe postoperative pain. This is one of the reasons why various alternative modalities have been developed to replace the standard posterolateral thoracotomy, such as muscle-sparing techniques and VATS [12]. Thoracic procedures are commonly associated with high pain. This further research allowed me to have a greater understanding of Thomas and his care needs through the deeper knowledge of the biopsychosocial effects of pain, I can now more effectively emphasise with Thomas in exchanges later in the week when exchanges occur. Deemed essential by both the CSP and NHS within the core values of physiotherapy. Caring is proposed as a guiding philosophy and a moral orientation that is central to clinical practice described by Ramklass, 2015 (13) in specific relation to students in developing skills for ‘emerging practice’.

Feelings II

During this experience in more independent clinical practice, I was surprised that feelings of confidence towards the proposition when initially presented continued until the end of practical assessment and interventions. This allowed me to conduct a more patient-centred subjective assessment as Thomas displayed some confusion and anxiety towards the presence of physiotherapists because he “didn’t want to do that movement stuff”. Introducing myself calmly and openly discussing my role and the purpose of my visit in this manner allowed the therapeutic relationship to develop as Thomas was made to feel comfortable. As we moved from assessment to intervention where my role became more of assistance in E70 and NP suction.

Evaluation I

Being proactive in my learning and studies allowed me to have a positive experience when given the opportunity to practice Independently. A skill deemed as ‘necessary’ within many job applications due to independence aligning with a ‘commitment to quality care’ as stated within the NHS constitutional values (14). I felt improvement can be made to my research skills, as much of my time was spent trying to locate and utilise reputable resources and case studies, which could have been reduced through more effective use of research search tools.

Evaluation II

In assisting intervention techniques I have aspects of the process of which need to be recalled in a more accurate manner such as the setup of the device. Alongside improvement to E70 handling techniques in regard to maintaining pressure between the device and patient airway in order to minimise loss of pressure, or the uncomfortable feeling of the patient exhaling when the E70 is providing a negative pressure for inhalation or vice versa. However my communication of techniques improved and the following feedback from my clinical educator to devise a structure for discussing clinical assessments and interventions with patients, I had improved in my ability to do so.

Analysis I & II

Interpreting the situation across both self-directed learning and clinical experience in combination, I am able to see how comprehensive service within the NHS is provided beyond the biological, psychological and social understanding of symptoms. But in order to adhere to NHS constitutional values, I must seek to be accountable to patients, service providers and also my own professional development in order to become an adaptable and effective practitioner. While being proactive leads to many unpredictable opportunities for further personal development and as such a proactive approach to development is better suited to a healthcare professional, than a reactive approach.

Conclusion I & II

In conclusion, I feel in addition I could have asked more questions of the MDT members during time spent within the ward environment in order to better understand the clinical reasoning behind decision-making outside of my scope of practice but remains highly influential for patient outcomes of care which the entirety of the MDT takes responsibility.

Action Plan I & II

This action plan is elaborated around 2 main lines: gaining some additional knowledge and training my experience by practising within the clinical environment.

Practically, I need to keep improving my fundamentals in CVR to be more patient-centred. It can be achieved by two main steps. The first step is to practice more active listening and to try to be more focused on the patient by paying attention to words used, personal goals, expectations and non-verbal language. I also need to ask more questions about the impact of the problem on patients’ personal lives, but also about their perception of the situation as recommended by Diener et al (2016). I need to increase my empathic motivation – the will to engage with the patient – but also my empathic skills by trying to deduce emotions from the patient’s verbal and non-verbal language. The second step is to establish a therapeutic alliance with the patient as soon as possible. I work on my verbal communication by asking open questions, summarizing, and clarifying when needed. Non-verbally, I try to use more body language and to have warmer behaviour. I try to be more enthusiastic, using more acknowledgement and reassurance.

These two main steps can create a baseline towards patient-centeredness.