From working within a team I have learnt that communication in health and social care underpins everything that professionals do and can determine the quality of service that patients receive. Poor communication between members of inter-professional teams affects the quality of care patients receive and can result in any number of bad experiences for the patients. I’ve noticed that some of the factors that contribute to poor communication include the use of professional jargon, abbreviations and poor handwriting. Within the acute setting, I have recognised both effective communication leads to greater patient outcomes. While poor communication has led to large physical decline, extended hospital stay and reduced potential rehabilitation. This highlights just a few areas I have seen communication impact care through verbal and non-verbal communication (written notes, electronic notes and system failures).

During this time on placement, I have been able to witness and participate in multidisciplinary team meetings and have also had the opportunity to work with different healthcare professionals such as physiotherapists and also have been involved in ward rounds with doctors and nurses. The ward I am placed had a great team. I always felt a part of the team, and that I was making a valuable contribution thanks to both my eagerness to take on anything they threw at me and, their inclusiveness and supportiveness. I learned that holding back and waiting for people to notice you is not a good strategy. Let everyone know that you’re interested every day, and opportunities will come your way.

My role and relationship with others within the clinical setting were very important to me. It was important for me to build the team member relationship with others as it helps to establish a mutual understanding and trust with other team members. When reflecting upon my own strengths and weaknesses, in relation to my role and relationship with others, I feel that whilst I am beginning to acquire an in-depth understanding of the role of the physiotherapists within the MDT, this placing giving me a fantastic opportunity to work closely with occupational therapists, a role which closely relates to my own role, and one I was keen to engage in. This department works very closely. With a shared MDT office where any role can work and communicate freely. PTs, OTs, Therapy support workers (TSW) & Speech and language therapists (SALT) all work together throughout each day. I have listed the priority of this as being medium to high as I feel that it is not possible to become an effective collaborative healthcare member without having an understanding of the roles of others with whom I am working. If there is a lack of understanding of the roles of others, I feel that it would be difficult to see why they are involved in the care of my patient, or even when it is appropriate to involve other healthcare professionals, inevitably leading to the quality of the care for the patient to suffer. Thus I made it in my best interest to interact more with others during the placement so that I could work alongside them confidently and work towards the same goals.

Being in an acute care setting, the kind of problem-solving that I did tend to be solving were immediate problems rather than long-term problems. For example, patients who can’t get up need to have a sponge and clean linens on their bed. However, each patient is different and often I couldn’t just perform the task without thought. The process of problem-solving has guided me in finding solutions to a problem. I have learnt that this process is effective and helps me make the right decisions. I have also learned to reflect on my decision so that I can see if the decision was the best or not for the situation. To assist me in problem-solving more complex situations, I asked my educator to challenge me with questioning regarding my practice and decision-making. Alongside my educator providing insightful knowledge into his critical reasoning and own decision-making.

Finally, I see it important to reflect upon my own communication skills within the MDT During my placement I was in a stroke unit. Being on this unit, I worked with many clients who suffered from post-stroke symptoms and many had difficulty with speech. The experience helped me learn the importance of both verbal and non-verbal communication. As an aspiring PT, I have to continuously sharpen my communication skills because I will be interacting with a more diverse range of patients in the future. I have to be able to establish rapport with each new patient and I can do this by communicating with them. I must maximise my communication with my patients because I can do a lot of things by communicating such as motivate, empower, educate and understand my patients despite cognitive changes.

This week I was granted the opportunity to visit Ward 3, a specific stroke pathway ward, acts as a rehab unit for patients before they are able to go home; either to receive further care or to be discharged from my care. This day within ward 3 has also provided me with the starkest reminder of what it can mean to work within a financially stretched NHS ward, giving me real cause for concern and compelling my act.

Of course, I am aware all public sector career choices face similar financial constraints and challenges, in the same week that this article hit the headlines, this placement week has really hammered home the reality to me. The unit on which I have been placed is, I am told, chronically understaffed by nurses and alleviating accommodation pressures elsewhere in the hospital. This has inevitably impacted therapies input, calling for much of our time to be spent providing personal care before commencing sessions and assisting in other care, with patients that, strictly speaking, shouldn’t be staying in a stroke unit. It has, however, also left me feeling uneasy and uncomfortable with some things I have seen. Now, I know what it is to work somewhere that is understaffed and I am realistic about what can be achieved and what has to be de-escalated in the priority stakes. I am, however, human. Human and with an abundance of compassion. Never is something like this excusable or mitigated and this is why I acted. Witnessing distressed patients left for almost an hour in urine or requiring assistance. My concerns were handled in a way I was not 100% comfortable with. Lacking surprise or urgency to support with a specific ongoing issue with a patient left in their urine for almost an hour, to which nursing staff and the acting ward consultant were well aware. After raising my concerns and the issue at hand, I managed to gain the assistance of the senior physiotherapists left to supervise me. Having felt I managed the situation with a mature, professional demeanor unaffected by the impact of I assume managing, dealing with and witnessing this during many years of experience left me feeling mixed emotions of initial guilt, leading to pride, leading to deep reflection to which this reflection makes up a huge part. In the end, I feel that what I had done was the right thing. I sort care, implemented care, provided feedback forms and attempted to reassure the patient. Documented the full exchange and following this left the notes written with the senior physio. I was reassured too, that I wasn’t alone when another member of staff voiced the same concerns to me in passing. I also noticed after reporting my findings, an obvious shift in my own effort to recognise where best practice care is not being provided and how I can bridge this gap, regardless of specific need. I can only hope that if I witness an event as I have done, I continue to feel secure and confident enough to do the same again over and over again.

Description

Feelings

Evaluation

Analysis

Conclusion

Action Plan

WEEK 1 Goals

• To be independent with taking in depth subjective history from patients and NOK.

• To independent with functional assessments-bed transfers, mobility assessment.

• Joint working with Occupational therapist while assessing patients.

Things Learnt / Experienced this week:

• The need to consider if the patient has a formal diagnosis (eg spinal stenosis or COPD) and how this would affect my ability to manage the patient / prioritise based upon diagnosis.

• Similar to above, the understanding and critical reasoning of symptoms severity (eg pain levels, presence of neurological symptoms, severe shortness of breath) is also an important consideration.

• Questions I have learned the importance of this week. Are the symptoms so severe an in-person consultation or referral is necessary? Is the patient suitable for D/C following PT/OT Assessment?

• It is also important to consider the chronicity of the condition. More severe and acute cases may need to be seen sooner and become higher on the priority list.

• My experience both clinically and within previous employment making me competent in manage of personal care is a valuable asset as a student-practioner.

• My lack of experience with managing patient discharge within the Leicester Hospitals Trust makes independent working within the department a challenge once patient planning and referral discussions with the MDT are required. This is an area of knowledge base and skill which I will seek to improved through engaging with the process when performed by my colleagues; seeking to ask questions and become actively involved where possible. I aim to be comfortable performing discharge/referral planning 4/52 from todays date (03/08/22).

Goals

• To be independent with taking in depth subjective history from patients and NOK.

• To independent with functional assessments-bed transfers, mobility assessment.

• Joint working with Occupational therapist while assessing patients.

Reflection of Goals

DESCRIPTION: This week I have undertaken 8 formal baseline assessments with supervision and collected subjective history for 10+ patients. The patients diagnosis/reason for admission varies across Respiratory, Neuromuscular, Musculoskeletal Physiotherapy and often involved two or more areas of direct assessment/intervention, with all areas requiring consideration within my critical reasoning. FEELINGS: This has been an enjoyable challenge. Being able to draw on my previous three placements across these disciplines has allowed me to complete necessary assessments with supervision/independently and do so with depth and detail. It required me to review and assess my knowledge coming into the RADS team, prompting me to review "gold-standards" "NICE Guidelines" and "Cochrane Reviews" prior to my start date; then in my first week, undertaking the review of specific outcome measures regarding falls, geriatric patients and the learning of the departments screening process in which the knowledge of specific medical conditions and their influence on treatment holds value for appropriate and safe practice. EVALUATION: Reflecting on this week having been tasked to contact 3 NOKs via telephone, doing an additional 2 calls independently without prompt shows my proactive nature and confidence. My CPD and additional time spent learning from various sources has allowed me to feel prepared and able to answer the questions of NOK, My educator(s), patients, and the MDT when asked of me. It has also supported my ability to ask appropriate questions when working under supervision or independently, acting with a humble and soft approach to each exchange. CONCLUSION: Having used the lessons learned through failure and success within previous placement experiences, I have been proactive prior and during my first week with RADS. A fast-paced and challenging department due to the necessity for thorough screening, critical investigation/reasoning and the ability to quickly adapt and justify assessment/intervention. At times I have learned that there is also more to think and consider than the first impression, never trust the notes and do your own investigation (i.e.: Don't be afraid to challenge previous investigations) and that there is true value in the ability to be proactive, therapeutically build relationships with patients/MDT and then apply knowledge. The demands of the department require understanding and depth of knowledge within PT and OT specific areas. An aspect I have yet developed thoroughly enough for independent practice as my knowledge of OT procedures during assessment regarding equipment/care need improvement. An area I have discussed with my educator during feedback (05/08/22).

ACTION PLAN: (1) Continue reading and CPD regarding geriatric patients, falls and red flags. (2) Seek to challenge my practice and seek for my educator to challenge my critical reasoning for assessment/treatment/discharge planning. (3) Continue to be proactive when starting early on Tuesday / Thursday and support OTs with the screening process, while using this opportunity to ask questions regarding OT/PT shared roles and how I can support them best during exchanges.

While unfortunately off sick with covid I have been undertaking self-directed learning to consolidate the information and knowledge passed to me by the multiple practioners' I have learnt from in my first week. With my educator for the week setting my initial goal (1/3) to independently complete subjective assessment, I tasked myself with collating the information necessary to gather into short-form to aid memory and remove any reliance I was building on use of the paper document to be able to take a subjective baseline without need to read off a sheet and write notes as I go. This benefits my practice and the patient experience as it can be integrated into a 'naturally flowing conversation', as opposed to a "tick list" that can become boring or irritating for the patient, reducing engagement and potentially impacting the patient-therapist relationship as this is often the first impression the patient receives.

Clinical Frailty Baseline (Taken from my "self-directed learning portfolio":

1. Environment: Lives w/, Pets, Accommodation Type, Stairs/Rails/Steps, Key safe, Lifeline

2. Package of Care (POC): AM, Lunch, Tea, PM - Frequency, Tasks/Aid,

3. Personal Care: Washing / Dressing, Independence, Bath/Shower - up/down, type,

4. Equipment: Shower Chair, Bathlift, Bath board, Bath Seat

5. Meals: Type, Snack, Drink, Level of Assistance

6. Eating & Drinking: Cooks?, Microwave?, Carry2Eat?

7. Domestic Tasks: Cleaning, Laundry - in / out / drying / away, Shopping - online, put away, decision making?

8. Mobility and Transfers: what, when and how often / how far –

W/S, WZF, Kitchen Trolley, Crutches, Scooter, Wheelchair (propelled vs self-propelled), Hoist, Rotunda, Bedbound

9. Falls History; # in 12/12, (2+ prompts referral) – where, how (trend), severity?

10. Chair Tranfer, Bed Transfer – (Lever(s), Toilet Transfer – (combi, FSTF,Raised Seat, Rails)?, Commode

11. Drives vs Public Transport vs Family/Friends vs Homebound?

12. Cognition – Old vs New Dementia? – 4AT Qs

13. Skin Integrity, Communication – Language barrier, Glasses, Hearing Aid, Glasses, Dentures

14. Continence / Elimination (urine/faeces/pads/catheter/stoma) – Urgency vs Nil Control vs Nightime

15. Medication – level of assistance/Dossett Box

During the creation of this short-form subjective baseline assessment I realised that many of these questions link to each other, and also that questions such as: (1), (3), (7), (8 - 11) - provide detailed information that informs my decision-making during the objective assessment to follow. This was prompted to me by my temporary educator for the week and in creating this tool above to inform my independence I am seeing more clearly how the objective assessment can be individualised to the patients specific needs. Below I will attempt to collate the necessary knowledge required to inform the "action" required from common answers within the common pathologies within the department.

Additionally from observing practioners and using a resource shared with me titled 'Initial Contact and Baseline Information' I learned the importance of the following:

• Medical notes​ - providing detail of MDT assessment: specifically detail regarding ongoing medical interventions / assessments.

• Ask the nursing staff how they are today/ how they transferred out or toileted​ - invaluable information from those who observe the patient most.

• Repositioning charts​ - providing detail of patient mobility/transfer and prompts prioritisation if lack of repositioning

• Nerve Centre - previous wards, previous admissions, clinical history etc. ​- informs past medical history and potential "pattern of admission"

Finally, I have learned the importance of not just valuing the initial "reason for admission", but understanding what the patients main concern during admission. An example from the resource is shown below:

"The patient has reduced mobility secondary to a fractured ankle​"

This may then lead to looking at their past medical history within medical notes / nervecentre to find out..

"A patients main issue now might be that they cannot walk independently but this is secondary to them having a fractured ankle because they had a fall at home. The patient has had multiple falls recently and has been taking antibiotics for a Urinary Tract Infection (UTI).​"

This then ties into the RADS Team, as looking at the example above, we can now see the patient was admitted due to a fall, however their main concern keeping them from discharge is current medical intervention for a UTI and multiple falls recently. Assuming the fracture has been x-rayed, there is now prompt to perform a "multifactorial falls assessment" - below is a quick, short-form version of common assessments used and recommended for use by the N.I.C.E Guidelines:

• Use RPE for intensity / duration (6 - 7 / 10) (10 - 16 / 20): Light/Hard (1)

• Timed up and go (TUG); used as both an assessment tool and mob activity. Standardised for 3m / altered assessment if able is a 10MWT (2)

• BERG Balance Assessment or to save time perform a "180 turn" and record # of steps

• 4-stage balance test: standing, instep, tandem, one-leg

During my clinical experience in week #1 I was able to both witness individualised use of these assessments, and with and without supervision perform assessments upon patients. Most frequently the 4-stage balance test and 180 DEG turn. Perhaps due to their ease of repeatability, objective data taken and clear measure provided to patient. This is alongside the patient being able to have a clear idea of "how they can improve".

These outcome measures above are then used to inform a "multifactorial approach" to falls interventions. Aiming to include and influence the following factors:

Multifactorial Goals of Falls Interventions:

1. Increase; mobility, balance, strength

2. Decrease; risk of long lie falls

3. Assess; intrinsic vs extrinsic factors

4. Influence; Confidence, self-esteem & Quality of life

Goals

• To be independent with taking in depth subjective history from patients and NOK.

• To be independent with functional assessments-bed transfers, mobility assessment.

• Joint working with Occupational therapist while assessing patients.

Reflection of Goals

DESCRIPTION: This week has further challenged my learning and development. With clear goals in place to act as an independently functioning member of the MDT by 11/11 of this my final placement, it is apparent to me the CPD and practical experience required for me to competently and confidently carry this out. I have learned the importance of being concise, coherent and clear with notetaking in order to successfully communicate with the MDT and adhere to best practice guidelines set by the CSP and the LRI and Leicester University Hospitals Trust. During exchanges where I have had opportunity to work under supervision to take subjective / objective baseline assessments I have been able to demonstrate effective communication, empathy and ability to discuss complex systems or concepts with language suitable and accessible to the patient. At times, during collection of the subjective assessment without use of the booklet to guide me, I have lacked the necessary attention to detail in order to collect a comprehensive baseline from the patient, gathering ALL necessary information. Often forgetting to delve deeper into how ADLs are performed and how often / how any mobility or transfer aids are used. This has required the PT / OT to step in from supervising to ask these questions. I have also recognised that following a clinical exchange the requirement to act upon the session for a discharge plan is an area I need to develop. This is due to my lack of ability to quickly and accurately recall the necessary stages required for discharge. Stages such as appropriate referral and informing MDT members or wider practioner external to the trust via telephone contact. This comes as an improvement from week 1 with RADS. I am now more often than not able to clinically reason if a patient is appropriate for discharge or not, however how that is then acted upon I am still developing as a skill, aided largely by my educator.

FEELINGS: During this week returning from illness I have felt proud of my ability to recall the initial practical skills learned and information provided in a short space of time, required for working within the RADS team. Information and practical skills which are mainly unique to RADS compared to my previous clinical experience. I have enjoyed the challenging nature of RADS and hope that in now settling back in, I'll be able to effectively continue my professional development to achieve an excellent pass and feel competent as a member of the team. I also feel challenged by the nature of work in RADS. It requires quick and accurate recall of information. Having confidence in this knowledge allows for safe and effective practice during prioritisation, assessment, treatment and discharge planning. This is an area I feel I have struggled with since my undergraduate degree, as I am a very reflective learner who struggles to retain and hold information without frequent reflection and exposure to practical use of said knowledge. My educator and the wider MDT have made me feel comfortable to make mistakes and answer questions when not 100% confident in the answer, and this has made the process of improving my recall of information easier, and to do so with more confidence. I hope to see this support my ability to achieve an excellent pass and work independently as a member of the RADS team by the end of this placement.

EVALUATION: I have been perhaps too reflective in nature during the start of this placement. Being apprehensive to work independently due to the nature of the wards and patients the RADS team operate to support often being seen a few times or once before discharge. Now feeling supported to ask questions, challenge myself and make mistakes I hope to be able to support the team and work towards independent working without the need for constant supervision.

CONCLUSION: I feel at this stage I still require supervision with the majority of tasks carried out day-to-day by the RADS team. Despite growing competence with subjective / objective assessments and the screening process, I feel my main weakness currently falls within discharge planning, with the ability to justify my prioritisation falling second to this.

ACTION PLAN: Clear S.M.A.R.T goals for each week to achieve end goal of independent work within RADS team.

Goals for next week:

(1) Clear and confident understanding of prioritisation to be able to independently screen and prioritise with minimal need for supervision / correction by the end of next week (26/08). PLAN: use prioritisation resources provided to further knowledge and practical experience with "mock screening".

(2) Add 1 - 2 patient records to Nerve Center each day next week, while putting through 1 - 2 referrals / calls to NOK each day to allow me to build up the confidence and knowledge of how to be concise with my record taking, and professionally appropriate with my management of discharge planning and referrals necessary to work towards full independence (02/09)

(3) Continue to be proactive when starting early on Tuesday / Thursday and support OTs with the screening process, while using this opportunity to ask questions regarding OT/PT shared roles and how I can support them best during exchanges.

(4) Over this coming weekend (20 - 21 / 08) I will be further developing my "RADS Learning Resource" in order to add the addition of a prioritisation heading to consolidate the vast considerations necessary for clinical prioritisation / screening within RADS. This has been started today (19/08)

Patient Details; registered blind, Hard of Hearing, Muslim. PC: Diarrhoea 2nd. Viral Infection

DESCRIPTION: Elderly patient admitted with a viral infection and Diarrhoea. She was registered blind 2 years ago and was hard of hearing, requiring a hearing aid. The patient was a devoted Muslim. The summarize the experience with the patient, she was mismanaged on the ward by nursing staff with a variety of issues. 1) Nurses entering her room without asking consent / stating their presence to the patient. This was the same when exiting the room with staff not informing the patient they had left. 2) The patient had a catheter in situ. This leaked, to which the leakage on the floor was covered with paper towels, not cleaned up appropriately and patient was left soaked. 3) Many nursing staff were unaware the patient was registered blind and hard of hearing. This was poorly marked on the patient information board above her bed, with the color of notes marked in the same color as dietary preferences. 4) Patient was not provided with assistance to eat, despite being registered blind and requiring support. 5) Patient was not provided with call bell within reach, and made aware of location 6) Patient personal care was generally poorly managed, with patient left soiled for 3+ hours on multiple occasions. These concerns and episodes of mismanagement were recognized by 1/2 daughters. This daughter was a member of staff at the hospital, previously a member of the SALT Team. She raised formal complaints with the ward manager and those in charge.

Once the patient was fit for therapy we saw the patient.

Visit 1: Patient was able to 1. Independently lie --> SOEOB | 2. STS to WZF independently | 3. Mob approx. 10m with supervision of 1 for guidance | 4. Toilet Stand --> Sit --> STS Independent with x 1 rail used. | 5. Mob approx. 10m back to ward chair to sit out.

Following the exchange we contacted the daughter (2/2) in order to gather a baseline, as it was difficult with English being the Pts second language. Baseline: Pt was assistance of 1 with all transfers, with husband (recent TIA) assisting as a full-time carer. Patient had private AM care call. Previously was provided by ICRS, but cancelled by the husband. The patient was stated to require assistance with all ADLs from husband including eating, drinking and toileting (wiping). The complexity here was that the patient appeared to be above baseline with mob / Tx as we witnessed the patient eat and drink without assistance beyond bridging the gap created by loss of vision. This was the same with Tx and Mob.

Visit 2: Daughter present and our presence requested by nursing team to provide update. Daughter was informed of session. Did not believe information provided and requested demonstration of transfer / mob ability of patient. Demonstration provided, patient at same as visit 1. Daughter raised multiple concerns re: ward management (listed in description) and with discharge planning. Daughter was not happy for discharge to home, despite QDS package of care offered. Daughter stated complaints with management, rather than reasons for concern at home. Stated other options re: D2A bed. Daughter stated this was not in patients interest and requested 24 hours to discuss planning with sister. Daughter (1/2) stated that patient previously was fully independent with mob / transfers in own home, requiring assistance with washing / dressing / cooking, but independently with eating / drinking when aware of environment.

Visit 3: discussion with daughter 1/2. Daughter was happy with discharge plan for home with QDS package of care. This would be for an initial 6 weeks, after which they would be financial re-assessed, and due to previous cancellation it was likely they would need to independently fund. Daughter was unhappy with this, stating her dad did not cancel previous POC, however system & ICRS when contacted stated it was cancelled by husband (dad). Daughter raised further complaints (listed in initial description).

FEELINGS

During the full clinical experience managing this patient, discharge and family concerns I felt my clinical reasoning and knowledge challenged. Due to the apparent complaints made by a family member I understood that I was under frequent scrutiny and any errors would potential damage the therapeutic relationship and impact discharge planning as a member of the MDT in a position of authority to discuss outcome with patient and family members.

Prior to the exchange I felt nervous, and questioned whether I would be able to manage a difficult situation where conflict had previously arisen with discussions between family & nursing staff. However during the exchange, once answering questioning and resolving disagreements in an effective manner. I felt more confident managing the exchange to be an effective member of the MDT involved in order to settle the concerns, manage expectations and arrange safe and appropriate discharge with the family onboard and in agreement.

Following the exchange I feel more confident in managing disagreements and potential conflicts in a professional manner. Knowing more about myself and what skills I have available to me to manage these situations.

EVALUATION

The experience was a positive one, due to us coming to an effective resolution regarding the discharge planning. In doing so we managed to calm the family (daughter) down, and potential reduce the agitation / frustration she had with nursing staff. She felt comfortable talking to us and thanked us for the time, energy and manner in which we handled the whole situation.

The experience went poorly due to a DSA discussing the patient requiring community hospital admission, despite clear and detailed documentation of discharge planning and all exchanges within paper-based documentation (patient notes) and online (Nerve Center).

ANALYSIS

Things went well as the OT and I approached the situation with the frame of mind to understand the family (daughters) concerns first and foremost, and create an effective rapport in order to manage expectations and previously raised complaints. We also used language, both verbal and non-verbal in order to build this effective rapport. Following the lead of the OT present I was able to improve upon this throughout the visits and exchanges involving the patient and family (daughters).

During a qualitative review of patient satisfaction with physiotherapy in the acute setting where patients were followed up 2-3 weeks post-discharge, it was noted that patients appreciated, enjoyed and respected physiotherapists who acted with an "authoritative, but very pleasant, bed friendly manner if you like, but factual way in which imparted knowledge is well communicated" (Sheppard & Anaf, 2010). Patients also mentioned that physiotherapists were often the member of the MDT who explained what was happening, what was going to happen next and most importantly, why it was happening (Sheppard & Anaf, 2010). This was effectively conveyed to the daughter during visit 2 and 3, and highlights why an effective rapport was so pivotal to effective discharge planning.

CONCLUSION

From this situation I have learned the importance of valuing the Biopsychosocial model of care. The situation placed me in a position where all three aspects of the model held large importance to the outcome of exchanges and having the effective clinical reasoning, knowledge and communication skills to deliver on the model is of upmost importance for my continued professional development.

Patient Details; LRTI, Nil History of falls 6/12 but multiple falls over last 1 - 3 years. Previous falls clinic referral. Nil POC. Wife is main carer (previous nurse). Medically fit when seen.

During a routine assessment of mobility / transfers and safe discharge planning, a patient accompanied by their wife and daughter was involved in a series of disagreements and conflicts. Between himself, and his daughter. Between the wife and daughter. Between the daughter, patient and wife. As well as, the daughter, other children of the patient and patient. These conflicts arose from a disagreement in the level of support the patient required for safe discharge and continued maintenance of safe living. The daughter felt that it was necessary for the patient to be sent home with the maximum package of care because the patient "couldn't do anything for himself" and "he is always at risk of falling". The patient and wife were happy with their current arrange of the patient receiving no public or private package of care and the wife bridging the gap of care needs. These care needs including cooking, cleaning, laundry, provision of food and drinks to an allocated location for consumption and the occasional assistance to transfer / mobilise if in a rush for the toilet.

On assessment the patient was fully independent with transfers, mobility and showed no requirements for support with ADLs. He walked with a WZF which he used prior to admission, showing some poor behavioral traits of using the WZF but beyond this, no need for supervision or assistance.

The daughter witnessed these aspects of the exchange, however was adamant the patient required maximum package of care. This led to frequent disagreements throughout the exchange. Including interruptions and emotional outbursts from the daughter. The patient and wife remained relatively calm and collected remaining firm to their values and opinions.

As the physiotherapist it is my role and expectation to proceed on the basis of a set of contextually-drawn values, one of which is the paramount imperative to avoid doing harm to the patient. This famous formula from the eponymously named Hippocratic oath has long served as a compelling principle for the medical profession, at least in its public pronouncements; yet the application of that principle can prove enormously challenging, especially as the medical professional often lacks sufficient training in the analysis of the matter from any point other than that of applied

therapeutic courses. The obligation to respect the wishes of the patient must be counterbalanced by the duty to the well being of the patient. In this respect the patient showed ability to perform ADLs / PADLS, Mobility and Transfers with Independence and/or support of his wife who was fit and able to do so. This meant that he had full capacity to make decisions regarding his discharge and package of care support at home. Knowing this following my clinical reasoning above, I was able to confidently discuss this with the daughter present and settle some of her concerns re: falls with options such as a wearable lifelines and assisted technology within the home. In doing so we were able to reach a resolution acceptable to all involved parties.

The resolution was found due to effective communication and use of clinical reasoning to justify decision making quickly performed on the spot, during the exchange. It was also important to understand when to become involved in conflicts and when to take a step back.

End of Week Reflection(s) + Goals for Next week.

Goals from last week:

(1) Clear and confident understanding of prioritisation to be able to independently screen and prioritise with minimal need for supervision / correction by the end of next week (26/08). PLAN: use prioritisation resources provided to further knowledge and practical experience with "mock screening".

(2) Add 1 - 2 patient records to Nerve Centre each day next week, while putting through 1 - 2 referrals / calls to NOK each day to allow me to build up the confidence and knowledge of how to be concise with my record taking, and professionally appropriate with my management of discharge planning and referrals necessary to work towards full independence (02/09)

(3) Continue to be proactive when starting early on Tuesday / Thursday and support OTs with the screening process, while using this opportunity to ask questions regarding OT/PT shared roles and how I can support them best during exchanges.

(4) Over this coming weekend (20 - 21 / 08) I will be further developing my "RADS Learning Resource" in order to add the addition of a prioritisation heading to consolidate the vast considerations necessary for clinical prioritisation / screening within RADS. This has been started today (19/08)

Feedback for consideration next week:

• Speed of prioritisation / clarity and concise notes during screening process.

• Effective baseline, strong rapport building quickly, adaptive communication (verbal / non-verbal).

• Positioning with assessments, manual handling is good/competent.

• Good discharge planning, evidence of clinical reasoning . Improvement to confidence / leading discharge planning

• Working well with OTs and adapting to different members of staff.

• Good with doctors, DSA, Pharmacists etc to co-ordinate treatments and integrate overall plan for patient.

• Effective clinical knowledge / reasoning. Good knowledge of pathways / protocols. Areas for improvements: implications for therapy.

Goals

1/7 - Ward Management

1. Lead discharge planning without input from OT if suitable. Manage caseload throughout the day.

2. Quickly and effectively prioritise and provide concise notes for MDT working

3. Notes: improving with logical step-by-step process, requiring some small adjustments. Some common error / mistakes made with missing 1-2 aspects.

4. Speed: preparing for majors in week 10/11, to be effective.

5. MDT working: Inform nurse in charge re: plan.

6. Continue to improve clinical knowledge re: implications for therapy (Observations).