The focus of this scenario is the learning that Emma, a first-year student nurse undertook while on a shift during her fifth week of a ten-week placement on ward A.
Emma’s key objectives during this placement were:
- To develop effective communication and relationship management skills
- To acquire skills and knowledge for post-operative care, specifically pain management, vital signs, and fluid balance.
- To undertake wound care and assessment
This is Emma’s second placement, her first had been on a medical assessment unit.
Emma is joined on this shift by:
- Grace, a registered nurse (RN), practice supervisor to Darren, Saima and Emma
- Darren: a third-year student nurse who is coordinating the care on the bay and acting as practice supervisor for Saima under the supervision of Grace
- Saima, a second-year student nurse
- Colin: a Health Care Assistant (HCA)
Emma has a practice assessor Sarah, who is not on duty today
Planning for her shift
Emma was allocated to work with Janet, as she had cared for her during her last shift, in the immediate post-operative period.
Emma's patient
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Female, aged 67
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Total abdominal hysterectomy two days ago for cancer
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Has a 10cm abdominal surgical wound, closed with clips, theatre dressing intact and due to be reviewed today
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Urinary catheter removed earlier today
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Lives at home and is a full-time carer to her husband, Robert, who has disabilities
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Janet is experiencing a lot of pain and feeling nauseous
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She is feeling extremely anxious and scared about both her diagnosis and how her husband is doing
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Diagnosed with cancer only two weeks ago after experiencing weight loss and fatigue.
Emma introduced herself, asking Janet if she required assistance with her personal hygiene needs, and if she could look at her wound and dressing. Janet appeared appreciative of this request, and she readily accepted. Emma took careful consideration of Janet’s privacy and dignity and encouraged her to do as much as she could for herself.
While Emma is assisting her, Janet discloses that she is feeling anxious about her diagnosis and how her husband is coping at home. Emma also noticed that Janet was in considerable discomfort and that her dressing was soiled with exudate. Emma, documented her observations, recording information concerning nutrition, fluids and skin care. Grace agreed with Emma’s records.
Putting the proficiencies into practice
The Standards of proficiency for registered nurses list the knowledge, skills and behaviours that every nurse must have by the end of their programme.
The standards are set out in seven sections called 'platforms'.
There are two annexes in these standards that list the skills nurses must have, and the procedures they must be able to do when they join our register.
One focuses on communication and relationship skills, and the other on nursing procedures.
Through some examples see how Emma was able to demonstrate certain outcomes of these proficiencies through her learning experiences.
What Emma did
Emma recognised and acknowledged that Janet was in pain and a discussion took place with Grace regarding evidence-based medicines and options to reduce her pain. Emma reflected on the World Health Organisation (WHO) pain ladder and the ‘gate control theory’ of pain; specifically, around the part that anxiety plays in the pain experience. This informed the pain assessment she carried out and Emma took time to actively listen to Janet to understand her pain and the source of her anxieties.
Emma spent time getting to know Janet and with her involvement developed and agreed strategies to support her. She noticed that Janet communicated openly when she was being helped with a wash; recognising that the privacy and intimacy in this situation helped Janet trust Emma to talk about how she was feeling. She took her time assisting Janet and made sure that she continued to feel able to be open about her concerns.
With Grace’s support and with Janet’s agreement Emma contacted social services to discuss Janet’s husband Robert and to ensure that he was receiving the support and care that was sufficient to meet his needs and enable him to stay at home. Emma explored the possibility of Robert visiting Janet, she was aware that they had been married for 40 years and had never been apart. Emma suggested that this could take place at a mealtime so they could enjoy eating together. Janet had mentioned that one of her main concerns was that Robert was not eating properly when she wasn’t there.
During the multidisciplinary round Emma was able to contribute, reporting that Janet had passed urine since her catheter was removed and that the team would be reviewing Janet’s pain as she continued to have difficulties, especially when she moved. This was important and needed to be prioritised as it had the potential to affect her recovery and delay the plans for discharge (also see Annexe B below).
Emma and Grace discussed how many people with abdominal wounds are anxious about this when moving and walking; Grace asked Emma to reflect on the importance of mobility and showed her how to support Janet’s abdomen with a pillow and to take some deep breaths to improve her parasympathetic nervous system.
What this demonstrated
Emma applied her learning about person centred communication and pain management to support Janet. She developed a good rapport enabling Janet to trust Emma to disclose her anxieties. Emma was able draw on her knowledge and experiences, thinking critically about Janet’s care, putting her preferences and needs first.
Emma demonstrated knowledge and confidence to communicate and manage relationships effectively with Janet and in the multidisciplinary team.
What Emma did
Emma reflected on Janet’s recent diagnosis of cancer and how she had delayed seeking help for her symptoms as she was busy caring for her husband. She discussed this with her supervisor Grace and ensured that the Oncology clinical nurse specialist (CNS) visiting Janet was aware of this to make sure that her recovery and plans for returning home would not be similarly affected. Emma made a note to do some further reading and reflection on this subject. On Grace’s suggestion Emma also had a discussion with the Oncology CNS, Kevin, and planned for a shadow shift with him. Grace, Emma, and Kevin identified some learning outcomes for this experience, and he agreed to be her supervisor for the day.
What this demonstrated
Emma recognised that Janet had prioritised Robert’s care needs and that this had influenced her decision when she experienced symptoms. This prompted Emma to reflect on how a person’s individual circumstances are linked to help seeking behaviours and health outcomes. This showed an understanding of the contribution of psychosocial influences, behaviours, and lifestyle choices to health outcomes.
What Emma did
Emma took the opportunity to share with Grace her knowledge and understanding of the anatomy and physiology related to Janet’s surgery. They discussed the rationale for a total abdominal hysterectomy compared to a laparoscopic hysterectomy. Emma, as a first-year student, provided a basic knowledge of the surgery and how the tumour had been affecting Janet. With this awareness Emma helped Janet to set some goals around improving her mobility with the initial aim of walking, accompanied, to use the bathroom to wash and use the toilet rather than using facilities at the bedside.
Emma recognised that Janet was experiencing pain on movement that was not being relieved with her current medication and that she was extremely anxious about her husband being home alone. With support from Grace, she made referrals to the pain team and spoke to Kevin about Janet’s anxieties. Grace and Emma had a conversation about how Janet’s anxiety and pain might affect her recovery and discharge. Janet expressed some anxiety about her wound and felt hesitant to move, concerned that the clips may come undone. Grace reassured Janet that this was very unlikely, and Emma was able to show her how to take deep breaths using a pillow to support her abdomen.
Under Grace’s supervision Emma documented Janet’s’ agreed plan of care and the progress made to date.
What this demonstrated
Emma linked her knowledge of relevant anatomy and physiology to Janet’s surgery and recovery. She was able to apply this knowledge to contribute to a joint plan of care that was person-centred with agreed goals. Janet’s wound was healing nicely and Emma reflected on the importance of anxiety and how this may be influencing levels of pain; this informed the decision to refer Janet to the pain management team.
What Emma did
Emma monitored Janet’s fluid balance and encouraged her to take oral fluids and a light diet. Janet expressed concern about needing to pass urine frequently if she drunk more fluids; Emma explained the risk of urinary tract infection (UTI) with a restricted fluid intake and, with Emma’s support, Janet drank more fluid.
Emma regularly monitored the six physiological measurements recorded to calculate the National Early Warning Score (NEWS 2) for Janet. This included: respiration rate; oxygen saturation, systolic blood pressure; pulse rate; level of consciousness and temperature. At the beginning of the shift these were being recorded every two hours, Emma calculated Janet’s NEWS2 score to 3, this is considered low risk (aggregate score 1 to 4) and so Emma asked Grace if the frequency of assessment could be changed. As a response to this Grace advised that Janet’s monitoring to be changed to four hourly. Emma updated Janet on this positive outcome and progress which helped to reduce her overall anxiety. Grace and Emma discussed possible signs and actions should Janet’s condition deteriorate.
What this demonstrated
Emma demonstrated she was aware of the importance of an adequate fluid intake and the risk of UTI following gynecological surgery and catheterisation. She was able to effectively communicate and manage Janet’s expectations.
Emma showed that she was developing the knowledge and ability to identify and respond proactively to early signs and symptoms of deterioration and contribute towards sound clinical decisions.
What Emma did
When Emma referred Janet to the pain team, she made sure that the team had all the relevant information including the pain score, wound condition, NEWS2 score, and the exacerbating factors such as Janet’s anxiety about her husband at home and her new diagnosis.
Janet had also been referred to the oncology CNS prior to admission. When Kevin the CNS came to the ward for a follow up visit; Emma spoke to him explaining that Janet had disclosed to her that she does not fully understand the diagnosis she has been given and the treatment plan now she has had the hysterectomy.
What this demonstrated
Emma showed an understanding of the roles of both the oncology CNS and the acute pain team and effectively communicated Janet’s care needs with them, ensuring that they are fully informed of factors affecting her care and were able to provide continuity and collaborate with her to meet her needs.
What Emma did
Emma made sure that all relevant risk assessments were updated for Janet as she became more mobile. This included pressure ulcer risk assessments, moving and handing assessments, pain assessment, falls risk, wound assessments and nutrition risk score. She was able to explain to Grace the importance of these assessments and talked through the actions they may take depending on possible changes and outcomes.
Grace and Emma discussed how person centred data from risk assessments are used to inform clinical audits and how this supports overall quality improvement in key aspects of the care people receive post operatively and through their care journey/pathway. Grace invited Emma to the next ward quality improvement meeting so she could see how this works and the implications for her future practice.
What this demonstrated
Emma showed she can accurately undertake risk assessments for an individual in an acute care setting and demonstrated an awareness of the importance of doing so. She also knew how to escalate concerns if Janet’s health deteriorated. In addition, Emma continues to develop an awareness of the impact of individual risk assessments on audit activity and quality improvement strategies.
What Emma did
While assisting Janet with her personal hygiene needs, Emma gained important information around her home circumstances. This included information about her husband’s care needs. Janet had made arrangements for Robert in preparation for her hospital admission; Emma gained Janet’s permission to explore the possibilities of continuing with the extra support when Janet returns home to help with her recovery. Emma acted as Janet’s advocate by documenting their discussion and shared her longer-term care needs and priorities with the multidisciplinary team.
What this demonstrated
Emma was able to effectively contribute towards jointly planning Janet’s discharge in line with her needs, wishes and preferences. She recognised that planning for discharge would need to take account of both Janet’s care needs as well as her husband’s showing an awareness of the principles and processes involved in facilitating safe discharge.
Annexe A: Communication and relationship management skills
What Emma did:
Emma reflected on the rapport, relationship, and communication she had with Janet and thought about the strategies that she used to help Janet feel comfortable in expressing her anxieties. Emma reflected on the communication techniques she has learned and the importance of working in partnership. She actively listened to Janet and helped her to talk about her anxieties gently probing, asking open questions and being non-judgmental.
For Emma these conversations were difficult at times as she had little experience of talking with people who have cancer; however, she recognised that Janet trusted her and felt comfortable talking to her. Emma felt very shy and lacking in confidence around difficult conversations and found it helpful to talk this through with Grace. She was sensitive and understanding but also recognised her limitations as she was not equipped to give specialist advice and should involve other members of the team. Aware that the oncology CNS, Kevin, was visiting Janet, Emma spoke to him about the nurse specialist role and continued to listen, aware that she did not want Janet to feel ‘fobbed off’.
Emma engaged in appropriate dialogue with Janet and during Kevin’s visit, sat with her, listened, and recognised the value of staying with her and holding her hand providing support in the absence of a family member. She then ensured that the outcomes of the conversations were accurately documented and communicated to Grace.
What this demonstrated
Emma showed that she was working towards the communication and relationship management skills outlined in Annexe A. She demonstrated active listening including responding to non-verbal cues (1.1) using prompts and verbal and non-verbal reinforcement (1.2). Emma showed that she understood the importance of non-verbal communication, specifically touch, when she sat with Janet during the Oncology CNS visit (1.3). In addition, she made use of open and closed questions and caring conversation techniques (1.4 and 1.5). In recording the outcome of her discussion with Janet she showed that she can write accurate, clear, legible records (1.8).
By engaging in a difficult conversation with Janet, Emma displayed that she has begun to work towards this skill (2.9). She conveyed compassion and sensitivity to Janet who at times was feeling extremely anxious.
Annexe B: Nursing procedures
What Emma did:
Emma undertook and recorded vital signs for Janet and calculated the early warning score. She took the opportunity to use the ‘manual’ sphygmomanometer to record Janet’s blood pressure as she was keen to consolidate the skill she had learnt in simulation at her university. The fluid balance chart was updated to record that Janet had passed urine since her catheter was removed. Working closely with Janet throughout, Emma completed a pain assessment and escalated her concerns about her level of pain when she moved. The nutritional risk assessment was updated, and Emma helped Janet select healthy meals from the menu.
Emma had a discussion with Janet about how much help she may need to wash. She was keen for Janet to maintain her independence but also wanted to make sure she felt cared for. Janet was able to wash herself with some assistance from Emma who ensured that she had clean bedding, her table was nearby and decluttered and the call-bell was accessible. While being assisted with a wash, Janet became distressed, Emma understood the importance of recognising anxieties and the impact this may have on her feeling safe, her recovery and plans for safe discharge. Emma made sure this was documented and appropriately communicated to the team.
As Janet’s pain became controlled, she was able to walk to the bathroom with Emma’s assistance finding this more comfortable than using a commode at the bedside. Emma updated Janet’s mobility and falls risk assessments to reflect her increased mobility.
Emma noticed that Janet’s surgical wound dressing had become soiled with exudate. She asked Grace to review the wound as she was concerned about this. Grace asked Emma what she knew about wound healing, and they explored the types of exudate that can be seen. They reviewed the wound together and concluded that the liquid seen on the dressing was serosanguinous drainage as it was thin, pink, and watery in presentation. Emma was able to explain that purulent drainage is milky, typically thicker in consistency, and can be grey, green, or yellow in appearance and if fluid becomes very thick, this can be a sign of infection. They were able to reassure Janet that the liquid seen on the dressing did not indicate an infection and was part of the healing process. She let Janet know the wound was healing nicely and emphasised the importance of keeping it clean and dry. Emma re-dressed the wound using an aseptic technique and documented the condition of the wound including the type of exudate seen.
In all care interventions with Janet, Emma was observed to act in accordance with local infection prevention and control policy and was able to articulate to Grace the rationale behind these.
What this demonstrated
Emma showed that she is working towards the nursing procedures outlined in Annexe B. She showed that she was able to recognise signs of emotional distress (1.1.1) as well as symptoms and signs of physical ill health (1.2.1). She demonstrated that she was able to recognise symptoms and signs of deterioration and sepsis (1.2.3) and articulated how this is being monitored by taking, recording, and interpreting vital signs manually and via technological devices (2.1).
In assisting Janet, Emma showed that she can use appropriate bed making techniques for those with limited mobility (3.2) and she endeavored to ensure privacy and dignity at all times (3.4). Emma also took appropriate actions with Janet to reduce or minimise discomfort (3.5).
While helping Janet to meet her care needs and support with hygiene and skin integrity Emma showed that she was able to observe, assess and optimise skin and hygiene status and determine the need for support (4.1, 4.3).
By redressing Janet’s surgical wound, Emma demonstrated the use of an aseptic technique when undertaking wound care (4.6, 9.3). In addition, she observed infection prevention measures including standard precaution protocols (9.1), using appropriate personal protection equipment (9.4) and safely disposed of waste (9.8).
Emma updated Janet’s nutrition risk score and thereby showed that she is using contemporary nutritional assessment tools (5.2). Furthermore, she recorded fluid intake and output (5.4) and observed Janet’s level of urinary continence and assisted her with toileting (6.1). Recognising that it was important to record that Janet had passed urine since her catheter was removed, Emma showed that she was developing an awareness in the assessment of bladder patterns and urinary retention (6.4).
Janet’s mobility was initially impaired following her surgery and Emma showed that she was observing and using evidence-based risk assessments to determine need for support and intervention to optimise mobility and safety and to identify and manage risk of falls (7.1).
With respect to best evidence-based practice with medicines administration and optimisation, Emma showed she was working towards gaining procedural competencies to exercise professional accountability in ensuring the safe administration of medicines to those receiving care (11.6) and administering medicines using a range of routes (11.9).
Test your understanding
Questions to prompt reflection and discussion
For Emma to achieve her objectives in relation to medicines management and optimisation, and discharge planning identify two proficiencies that Emma still needs to work on and what learning opportunities would you consider might be available for her in your area to achieve this?
For example, Emma could spend time with the departmental pharmacist, who could act as her practice supervisor to work towards Annexe B, 11.2 “recognise the various procedural routes under which medicines can be prescribed, supplied, dispensed and administered; and the laws, policies, regulations and guidance that underpin them” and Annexe B 11.11 “undertake safe storage, transportation and disposal of medicinal products.
For discharge planning Emma could attend the multidisciplinary (MD) meeting to discuss discharge plans and thereby work towards Platform 7, 7.10 “understand the principles and processes involved in planning and facilitating the safe discharge and transition of people between caseloads, settings and services”.
Emma will be spending a day with Kevin the oncology CNS, what objectives could be set for Emma to achieve while Kevin is her supervisor for this experience? If you were Emma’s practice assessor, what feedback would you ask Kevin to provide?
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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