#physiotalk student takeover

An amazing week of opportunities! A chance for students and physiotherapists alike to engage, learn, facilitate and collaborate with fellow students, qualified physios and the wider health caring professions as a whole. Let’s get involved …NEXT WEEK!!

physiotalk

Students are the future of physiotherapy and healthcare and from 20th April until 27th April 2015 they’ll be taking over the physiotalk twitter account, as well as organising and hosting a #physiotalk discussion on getting the most out of placements on the evening of Monday 27th April at 8pm BST. It would be fantastic if the whole physiotherapy tweeting community supported our student takeover team during the week both with tweets and discussions through the week and of course during the #physiotalk chat.

Our aims for the week:

• Promote student issues via the @physiotalk twitter account
• Engage physiotherapy students in twitter discussions that are led by students and important to students
• Develop the ‘takeover’ tweeters skills in running a twitter account and hosting a #physiotalk chat

About the takeover team:

The takeover team are all current physiotherapy students who are involved in the CSP student network supported by our two…

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It’s About Progress Not Perfection

Week Five

I have been thoroughly disappointed not to have blogged in my usual way over recent weeks. The purist in me will never truly forgive the absence of weeks three and four blog! That said, I do have some exciting grounds for mitigation, and, given it’s just you and me that will read this anyway, I won’t mind if you don’t! So, I’ve not had chance to share my half-way assessment feedback, my poignant patient interactions, my experience in elective surgical theatres nor my interview episodes…so much has happened since my last blog entry. I must also not forget, in my haste to bring you up to speed, to acknowledge that fact that yesterday saw me complete my final ever Friday as a student on clinical placement. It hardly seems possible that I am now marking the ‘lasts’ of everything student-based when so recently I was floundering and flummoxed by my ‘firsts’!

Half Way Feedback

As hoped, I received no surprises when being given my feedback. I was congratulated for my interpersonal and communication skills and reminded I need to broaden my scope of treatment options, although my educators recognised my awareness of my own learning needs and limitations, reminding me not to be over-critical of myself…Who, me? Never! I am encouraged to continue as I have been progressing over the course of the placement. Phew, on track then I guess?!

From Head To Toe

I often find myself reflecting back to my second placement experiences whilst here in outpatients once again. Working within a different team, in a different trust, serving a different geographical community, has provided a remarkably different outpatient experience. For this I feel grateful. Not only has it given me the opportunity to further develop my neuromusculoskeletal (MSK) handling and treatment skills, it too has demonstrated to me the potential differences in patient experience. In one department the approach was quite ‘hands-on’ with a focus on manual therapy, the other much more ‘hands-off’, with emphasis on patient self-management and coping strategies. I have also been exposed to two very different kinds of commissioning contracts in service delivery. While both departments received referrals for ‘in-house’ trauma and orthopaedics (fractures, joint replacements and surgical rehabilitation) only one received GP-led referrals for neck and back complaints, the other being outsourced to the private sector. Conversely, whilst on my first outpatient placement I was able to treat so-called ‘peripheral joint’ referrals which my current placement experience is lacking. This has meant that, across both placements, I have managed to experience a full spectrum of outpatient referrals, including chronic low-back pain, osteoarthritis of the knee, whiplash-associated disorders and tendon ruptures. I feel privileged to have been able to experience this as a student and have grown really quite fond of MSK physiotherapy as a consequence.

An Understudy Role

Surgical Exsanguinator – used as a tourniquet during total knee replacement surgery

I have been lucky enough to be able to witness first-hand a day in the life of an elective orthopaedic theatre this week. Organised by my educator, in response to my request to gain a greater insight to the surgical procedures I was subsequently rehabilitating, I spent all day on Monday in theatre! Arriving first thing, I was swiftly adorned with a set of surgical scrubs, a pair of rather fetching white Crocs and a hat and mask to finish the look! What followed was a jaw-droppingly amazing experience. I spent some time with the anaesthetists, observing their role, watching patients receiving varied levels of sedation such as spinal blocks and general anaesthesia. I then watched with great interest as the surgeons performed arthroscopic knee surgery, but what I was really there to see were the later total knee and total hip replacement procedures. I was not disappointed! I was quite literally an arm’s length away from the business-end of the surgery, seeing everything from an unobstructed view! I was particularly fascinated by the patient who lay on his side chatting away wide awake, whilst separated by a blue sheet out of view, his lower limb was contorted across his body with his knee pointing backwards! The precision with which the surgeons dislocate, insert prosthesis, relocate, test, dislocate, cement the hip joint was awe-inspiring! Hammering, drilling, sawing…bone fragments, flesh and blood. Nothing perturbed me – and I was pleased not to be one of the recounted observational students that had previously been scraped off the floor post-fainting episode! That was until the stench of the bone cement hit me! Being pre-mixed by theatre practitioners with a stop-clock ticking I have never smelled anything so repugnant in all my life – and that includes the experiences that will stay with me from my time on the burns and plastics placement! I was able to retain my composure and upright posture but oh deary me, that smell was awful!

My day in theatre meant I know have a much better idea of what a patient experiences and the extent of the surgical intervention. I am also in a more informed position when managing post surgical joint replacement patients in future. Oh, and as an aside, the hip is a really rather deep joint – who knew!?

Interviews

Part of my mitigation for temporarily shelving my blog posts has been my focus on securing a physiotherapy post to progress into on graduation later this year. It has come around insanely quickly and I was somewhat unprepared when my preferred Trust released an advertisement on the NHS jobs website. Given a gentle nudge by a previous educator I decided to apply to ‘see what happened’. I visited the CSP website to consult their survival guide, perused the ever-useful archives of Physiotalk, consulted various contacts both on- and off-line and familiarised myself with the Trust and the job specification in a bid to write an adequate personal statement. Whatever I did, it worked and within ten days I was called to interview with a week’s notice. The interview process was gruelling for me. The only other experience I could liken it to was a distant memory of my recruitment assessment day for the Metropolitan Police. I know some people shine at interview and manage to excel; I am not one of those people! Various formats of assessment, including group tasks, a practical element and a panel interview ensued. I am self-critical, this I know. However, I was certain I had not performed to my best abilities and stress and nerves had impaired my performance. “Oh well” I thought as I resigned myself to having to repeat the experience. I was genuinely surprised and frankly elated to be offered a permanent band five rotational post to start after graduation this summer! In my blog absence I have also been applying for another online-based role which again entailed a personal statement and interview. Once again, I could not be more pleased to share the knowledge that I have been successful in this pursuit also. Perhaps later blog posts may expand on this role.

Final Week Ahead

Next week sees me complete my student placement experiences. This in principle means I will have also completed my blogging journey. I have found the process of writing a reflective blog an invaluable addition to my studies. A journey of self-discovery but also an opportunity to self-regulate my learning needs. I cannot imagine it will have served its purpose in full given the learning I still have to do within my first band five role. The feedback and interactions I have had from this blog has fuelled my drive to keep it going, even when workload is high. I look forward to concluding my student experiences next week in my final blog entry and welcome your comments as always.

 

What Kind of Therapist Will I Be?

Week Two

A week of exploration has given me much food for thought. I have had various opportunities to instigate conversations with the current clinicians in the department, in an attempt to acquire more knowledge! I have been exposed to many different patients, with many different conditions. I have also had patients with quite similar conditions yet very different treatment needs. As I sit here hammering away at the keyboard ‘Jessica Fletcher’ style, I realise just how detective-like outpatient physiotherapy can be, and put simply, I am loving it!

In-service Training

Being a part of the department’s in-service training (IST) sessions has been invaluable for me. Not only is it a place to consolidate knowledge and hone handling skills, I have also found it a pivotal event in modifying my assessment techniques. Prior to the most recent shoulder IST, my objective assessments for my shoulder patients were all very different from each other. Until this point, I had been planning my objective assessments based on the subjective information I was receiving from the patient. When taking a history, I was looking for key information that would lead to a suspected structure or joint, planning then to use specific tests to confirm my theoretical diagnosis. What I had not appreciated, is how narrow and specific my objective assessments were becoming, and not always for the best. I have realised that in fact my assessments were hugely vulnerable to confirmation bias and leaving me little room for differential diagnoses. I would almost ‘stop looking’ if I gained a positive result for a test. Of course, in principle this process is fine, provided the patient responds to the chosen treatment and symptoms dissipate. However, it always leaves me, and consequently my patient, hugely vulnerable to potentially premature treatment decisions. Following the latest ISTs I have attended and from discussions with other clinicians, I have since decided it would be more beneficial to have a standard shoulder assessment – with a standard set of specific tests. True perhaps, this will mean I assess my patients with a standardised ‘shoulder assessment’ – but at this stage , I have more to gain from rote learning the battery of specific tests for a given joint. By assessing every shoulder with the same tests I am sure I have gained as full a picture as possible before I diagnose and then treat. True also, that I will then have maximised my chances of handling practice and ensured I am familiar with the available tests, rather than the current, ‘oh, I haven’t used the<insert special test here> in a while, how do you do that one again…?’ Without the IST and the discussions I have had, I would perhaps not have modified my approach or changed my assessent technique. Of course, in the wider NHS context of clinical governance, these IST sessions have meant I will have, probably, become more clinically effective in future assessments. As a consequence, I can now directly appreciate the need for these ongoing education and training, idea sharing and reflection ISTs for clinicians and welcome them in my future career.

Strapping & Taping

Now, unless I inadvertently snoozed and missed it, the only teaching we were given in university on this subject was a whistle-stop tour in a single classroom-based session at the beginning of year two. It lasted no more than an hour or so and for me, really didn’t take on much significance. I am now far more keen to learn its uses and potential benefits as I near the end of my undergraduate learning, realising now how useful it can be as a treatment adjunct in some conditions. I am aware the ‘jury is out’ in terms of evidence and I have heard various suggestions for its method of function, from aiding lymphatic drainage, to providing proprioceptive feedback to the wearer. I am a student and as such very much undecided on its place in treatment in terms of personal opinion. I do know however, that many experienced physiotherapists have their opinions, from both sides of the fence and I often watch with interest when the subject is debated. For now, I am happy to experiment with such an adjunct, along with other such highly debated treatments as electrotherapy, in a bid to find what works for a given patient.

Who Am I?

As I near the end of my studies I am finding myself wondering what kind of therapist I will be in future practice. Will I be a fad-follower, a traditionalist or another kind altogether? I don’t know is the answer. For now, I am happy to base my choices on evidence available to me. With no experience or anecdotal preferences I am led by my own musings and what I can glean from the research that has already been carried out. This week I was told not to concern myself with how a particular treatment may be working, but to be more concerned with the fact that it does and leave the whys and wherefores to the researchers. For my enquiring mind this does not sit well and for me to justify my treatments I feel compelled to be able to explain to my patient how something is working. I know too though, that the constant questioning and pondering in and of itself is exhausting, so for now, I might just have to relax and passively ‘accept’. I could spend a lifetime looking for some of the answers I seek in the physiotherapy world and I know some do devote their careers to such things. Perhaps, for me, research may well be an avenue I revisit and want to pursue? For the time being I continue to focus my attentions on completing my undergraduate studies and beginning in the world of NHS rotational physiotherapy…which reminds me, I should be preparing for my first band five interview next week! So, I must bid you farewell…

 

 

It’s Good to Talk

Week One

I am not quite sure where the last two and a half years have gone, but it would appear I have just completed my last ever week one as a student physiotherapist! These final two hundred hours see me on a second outpatient placement working in a trust I have not previously experienced. The usual unsettling feeling of knowing nothing and feeling utterly out of my depth dissipated quickly this time around. My focus for this outpatient experience is exactly that – to gain as much experience as possible and to continue building up my toolkit. Thankfully, this time around I have my learning from last September to fall back on which has given me a sense of confidence. I feel adequately confident that my subjective assessments are pulling the relevant and appropriate information for me to plan and carry out an objective assessment focussed on the structures I think may be at fault. Phew! Chance then, for me to focus my efforts on the treatments I offer and the caseload management rather than ‘where to put my hands’ or which direction I should face for any particular assessment technique! I must take heart from this, given that not everyone has the opportunity for a second ‘go’ at outpatients. I really enjoyed this area of practice previously and feel lucky to have been given another ’round’! I had forgotten however, just how many questions fill my head with this area of practice. It also makes me acutely aware of the language we, as clinicians, use with patients and what potential impact these can have. I imagine, in these final weeks, I will be turning to the ever-supportive and informative Twitter community for guidance and advice as I continue to forge a path into the world of qualified healthcare.

Evidence Base

Revisiting outpatients for a second time as a student affords me the chance to further explore the evidence base for the treatments available, in turn, helping me to choose as well as enabling me to provide treatment choice to my patients. Whilst it is my clinical reasoning that will arrive at given treatment choices, I am aware that the patient should be included in this decision-making process. Without their input they are no more than a passive receiver of information and advice; I want to help people to help themselves with guidance and support. I wish to promote self-efficacy and empower my patient to feel confident and able to achieve their goals.  I hope to focus my efforts this time around on exploring the clinician-patient relationship and the factors that can influence it. I have been signposted to the flag system already this week in conversation with clinicians about chronic low back pain. Whilst I am clear on the red flags and aware of potential yellow flags, I have little knowledge of other levels in the system. I have a genuine interest in motivators, facilitators and barriers to patient concordance and a wish to help those I treat. By broadening my awareness of these, perhaps I will better equip myself to recognise them and in turn overcome them in partnership with the patient. Idealistic perhaps? Well, I am a firm believer in modelling my behaviours and practice from ideals. I have a strong sense of what I want to achieve by joining this profession; I care and I have compassion. If I can make a difference to someone, however small, then I have achieved one of my goals.

Observations

I talk here of observations made of me in practice, by my educators, rather than the objective observations we make as clinicians. This first week has felt wonderfully frustrating – I can say ‘wonderful’ now after much discussion with peers and family members, processing my thoughts and associated frustrations. As I moved through week one I detected a sense of irritation at the constant monitoring I was under. Every patient I have seen has been with my educator present, sat conspicuously in a corner attempting to make their tunic blend into the decor behind! A swift “ignore me, pretend I’m not here” from my educator, addressed to the patient and I would carry out my appointments. Inside I was feeling disheartened by their presence, imagining all the permutations for the reasons why perhaps they were scrutinising me so closely. Might they be doubtful of my skills or knowledge? Had I unwittingly given cause for concern in some way? Perhaps they had even received prior warning I was unaware of!? I was baffled but continued silently in my frustrations, deciding it was better to ‘put up and shut up’ than seem like a problematic student in week one! By Friday, I felt ready to explore their thoughts on progressing me to more autonomous practice, with perhaps windows of time alone with patients. It was well received and I was assured that week two would see me given more space and freedom. A well-timed discussion on my part or a decision that had already been made on my educator’s part I will never know. However, from this I have affirmed how important effective two-way communication is and that in fact people, generally speaking, are not mind readers! I have also learned, perhaps, a more pertinent lesson. I can remember clearly the feeling of utter terror when told I would be alone with a patient for the first time in an outpatient setting back in September. I knew I had to make the leap but felt hideously ill-equipped to ‘go it alone’. This time and with five months extra studies under my belt, I feel eager to move into more autonomy – a wonderful signifier that, maybe, I will soon feel ready to qualify. When you consider the timeline in front of me, it is all rather timely and fortunate in fact, as soon I must! My only hope is that next week serves to reward my search for more freedom and I am not faced with the most complex patient that ever existed!

T-200

Week Six

So, as quickly as it began, it has now ended. My six weeks in the community flew by, much like the rest of the course! I’ve learned a lot of important lessons during this placement – many of them about myself and what kind of physio I will make in the future. Before embarking on this placement, I’d heard many people speak of community-based physiotherapy, some of them my cohort peers. I’d heard both positives and some negatives. I am generally one that ‘speaks as she finds’, trying not to be swayed by others’ opinions before experiencing something first hand. I can now draw on personal experience to make a balanced view for myself of what it means to be a community physio. What I thought would be an ‘easy’ placement was anything but. I say that, not for its demands of me as a clinician so much as the light it shone on my reflections in practice. The ‘shift of power’ was stark and exposing – a valuable lesson I will cherish when returning to the outpatient setting next time around. The advantage of treating people in their own homes is clear and, for me, this placement has completed my grasp of the ‘circle of care’. I now truly understand what it means to ensure a safe and well-planned discharge. I have also sadly witnessed what can happen when someone is sent home from hospital without adequate support in place. That ‘uncomfortable feeling’ I experienced on my first placement, when I judged someone as being unready to return home despite being medically fit, suddenly no longer feels uncomfortable. To advocate for a patient and ensure I am acting in their best interests is what should really matter, not whether there is pressure from above to free up hospital beds.

Autonomy

Surely, the holy grail for any student physio is the quest for increasing autonomy? I know I strive for it and feel it more and more as my placements progress. With each passing placement, the switch from observer to the observed comes sooner and sooner. My educators even have sufficient confidence in my abilities to let me get on by myself. In the early days this was a constant source of terror for me and my confidence was so wildly mismatched I presumed they must have simply lost their minds! My progress and development have boosted my clinical confidence, not quite to the same level as my grades suggest I am competent, but I am nevertheless getting there. Thankfully, and for me most crucially, my patients have had every faith in me and have remarked as such. At least I have seemingly shed the cloak of outward fear! I am no less uncertain; just much better at hiding the fact! Of course with autonomy comes accountability and my visits to the core dimensions of the Keys Skills Framework (KSF) are increasingly frequent as I endeavour to better understand my future role and professional function. It is within these closing months of my qualification that I seek to better understand my future role as a professional. It is not enough for me to receive my classification, apply for my first Band 5 role and rotate. I want to bring the best of myself to the role; to build a career for myself and make a difference. In my view, to do this effectively there is a need to communicate; communicate with everybody at every level. Reflections on practice make this an easier task, although as Ella brilliantly acknowledges in her recent blog post, it is crucial reflections are focussed for them to be of value. Communicating effectively with an educator can make a huge difference. Not only does it let them in on your thought process and therefore your clinical reasoning and treatment justification, it also allows them to reflect with you and help the process be whole. Countless times I have learned that my perceptions can be skewed by my desire to not just be good, but the best I can be. My educator was always willing to discuss cases with me, to listen to my ‘reflection on action’ and sometimes get a glimpse of my ‘reflection in action’ ramblings. I have learned the merit of doing this but also, that in fact, to be an educator takes patience and.. to be my educator an abundance of it!!

Final Grading

Always a source of shared student nerves and many an anxious final week performance, the final grading can never be avoided. An exposing and sometimes painfully honest exchange between student and educator. For me, I have been ‘lucky’ enough to do well in every placement so far but I am not stupid enough to think this is ever a given. I take my feedback very seriously and try my best to take it forward with me into my next placement. It is, perhaps, where I learn the most; certainly I gain the best insights here, for where I need to focus my next attentions if I am to sustain my grades. It is hard to remember sometimes, grades are not the be-all and end-all. It is very probable that within a short time my final degree classification will very rarely be brought out for an airing. However, so close to the end of the course it is difficult not to measure my final progressions in percentages and equivalent credits. If my tutors, lecturers and placement educators are to be believed, I will succeed in being a very good physio whatever the grade. For the perfectionist in me, anything less than ‘my best’ will disappoint.

The Tunnel

There is now a distinct, almost palpable, shaft of light penetrating from the end of the ‘student tunnel’. Just 200 hours separates me from clinical competence to practice. Just. A momentous final six weeks for me to pile on the pressure and make incredible demands of self. Or, conversely an enjoyable finale into clinical practice; a chance for me to hone my skills ready for my first post…I fear the former will be most likely; I can hope of course for a surprise! For now, I must return to University and consolidate my learning. The ‘dreaded’ dissertation looms in the background but right now pancakes are my main focus! Join me on my final clinical journey from the 27th February…just the small issue of a half marathon to get through first. If you have taken the time to read this blog, please spend a moment longer to look into the wonderful work Chestnut Tree House do, and help me to help them to continue this by sponsoring my half marathon here. Thank you.

Making Every Contact Count

Week Five

I have met numerous new clients this week and come across some rare and complex conditions. Each new scenario has provided me with opportunities to stretch myself, to learn new skills and broaden my overall knowledge. Unlike my earlier experiences of encountering new and unfamiliar conditions, this week I have felt content not knowing. My usual frustration and anxiety has left me, leaving enough freedom for me to actively seek the information I need to better understand a particular condition. Whilst not altogether second nature as yet, it has afforded me to feel able to say I don’t know and be ‘OK’ in doing this. Ordinarily I would be panic-ridden and all but paralysed by a mental block as my mind races to find the right answer. I’ve learned it is far more beneficial for all involved to be frank and honest, to acknowledge and admit the gap in my knowledge. I can then attempt to bridge the gap and return with an informed response. The deer in the headlights of placements gone-by is much less evident in recent weeks – this community-based environment has really emphasised this transition for me. I find great comfort in reflecting back upon my previous placements. For me, it consolidates my development and confirms, in times of doubt, that I am progressing both in clinical skills and professionalism. This week also saw me conduct a second visit following my horrific experience of week two. I am pleased to confirm I was confident and composed throughout on this occasion and managed a comprehensive and unassisted appointment. Once again, a pleasant confirmation that I am continuing to learn from my experiences!

Making Every Contact Count

I have been visiting one particular client for three weeks. They suffer with what they describe as their ‘legs giving way’ on a regular basis, resulting in falls around the home. I was unsure what was causing this weakness, unable to find any glaring or obvious deficits upon first objective assessment. I observed a generalised ‘sinking’ of the knees on prolonged standing but this was always rectified with minimal verbal cueing. On first meet, I was aware of some underlying ‘yellow flags’ but whilst mindful of their existence I did nothing more with them at that stage. After each appointment I revisited my SOAP notes and replayed my visits, looking for something I may have previously missed. I returned a week later to find an identical scene and a sheepish individual admitting to having neglected their prescribed exercises. We spent some time exploring this together in conversation. There was a lot of middle-distance staring and shrugging on their part; for me, a real need to understand their motivations or lack thereof. Suspending judgement was simply not enough to help bring about change. I needed to understand why they were unable to complete their exercises when they spoke of a desire to leave the house and go on short walks? I suggested some simple strategies to build exercise into an already established daily routine which were politely met with a nod of agreeance. I left the visit feeling I had made no difference; I suspect I may return to a similar situation in the coming week. What this client has given me, is a true sense of what merit there may be in such skills as motivational interviewing (MI) (Rollnick & Miller, 1991) or other such cognitive-behavioural therapy based approaches. My main goal as this client’s physiotherapist is to assist in bringing about change, yet I know change must come from within. I am well versed in the various models of change, for example Transtheoretical Model (Prochaska & DiClemente, 1982) and Health Belief Model (Rosenstock, 1974) and my previous studies and interest in psychology have carried through into my healthcare career. I have already chosen to focus on MI for my final year dissertation and this clinical experience has cemented for me, the relevance of such an approach. I would dearly love to feel more equipped to adequately explore and help resolve ambivalence with my clients. For now, I have only the rudimentary understanding of the literature I have been reading to fall back on when trying to help clients weigh up their own benefits and barriers. As I progress in my career, I hope to pursue this approach as an opportunity to further my clinical skills and ensure I deliver effective healthcare; all the more important when considered against the backdrop of the Public Health England’s (PHE) pledge to “help people to live longer, healthier lives by reducing preventable deaths and the burden of ill-health associated with smoking, high blood pressure, obesity, poor diet, poor mental health, insufficient exercise, and alcohol”. I see my role, as future physiotherapist, ideally placed to help achieve this for all those I make contact with.

Looking Ahead

Whilst I am full of ambitious ideals and motivation for future passions, for now I must use those skills I have acquired to do the best I can. I have much still to learn but look forward to my final week within the local community. These poignant experiences on student placements are the catalysts I need to drive me forward towards the end of my degree course. It is here, at the start of my band five journey, that I will continue to learn and grow as a professional.

A Surprising Lesson

Week Four

Thankfully my previous reflections have made for a much more comfortable and assured feeling this week. I have managed to ‘calm down’ and enjoy the placement experience for what it is rather than tying myself in knots about what I do not know. I have also been reassured by my ‘halfway’ review with my educator; no surprises regarding where I need to focus my attentions and some confidence-boosting positive feedback about my performance. I’ve also been given my own caseload to manage now and this feels the right time for me to step things up a gear. I distinctly remember in the not too distant past discussing with my peers how keen I was to ‘get out there’ and go on placement to consolidate some of our classroom-based learning. It seems almost unthinkable that I have only eight weeks left of being a ‘student physiotherapist’. After that, the next time I step foot on a ward or in a department I will be a junior physiotherapist in my first post.

The Spice of Life

I have made no secret of the difficulties I have faced in adjusting to life as a community physiotherapist. However, I have perhaps been so preoccupied with those difficulties that I have not allowed myself sufficient time to fully appreciate the positive aspects of this area of practice. Each day this week has seen me visit clients who have presented with challenges that have called on all areas of physiotherapy. Addressing extensor lag in one client, moving to respiratory treatment for another and finally providing cues and strategies to help a client manage their Parkinson’s Disease symptoms – the scope and variety really ‘switch me on’ and these examples were all from a single afternoon. I have also had a chance of use a number of scales and outcome measures I had not had a chance to ‘try out’ previously, such as the Elderly Mobility Scale (EMS) and Hoehn & Yahr Scale.

Safety vs. Independence

A difficult part of this role is acknowledging the limits of practice and where the line must be drawn between my clinical practice and a client’s own personal decision-making. We have been asked this week by a client if they ‘should still be driving’; by another if they should look to give up their home to seek additional carer support in a residential home. Conversely, one client looked to us to advocate for them in their quest to return to their own home following temporary residence in a nursing home. All such difficult questions from people who essentially look to us for guidance and support. I am clear where my own professional boundaries lie, in what I can offer advice and when it is inappropriate to become involved; what I find hard is remaining emotionally detached when faced with a tearful distressed individual who really knows the answer to their own question, yet is struggling with the reality that they may never return home or drive again. I have found myself fighting back tears as I feel their anguish and frustration, and sometimes defiance at letting go of what little independence they retain. A curious situation to find myself in – struggling with emotional detachment – when I consider just how skilled I had become at separating empathy from sympathy in my previous career. Of all the aspects of physiotherapy practice and its juxtaposition with my previous career choice, never did I think I would find lessons to learn in dealing with the emotional aspects of the role.

Final Fortnight

My final weeks in the community offer lots more lessons I am sure. The exposure to novel situations and conditions continues to broaden my, as yet, limited experience. I look forward to leading on my own caseload and recall the great pleasure and sense of triumph this rite of passage afforded me when working within an outpatient setting. I shall resolve to continue in my new-found sense of calm and enjoyment, taking from the experience as much as I possibly can in the time I have left! Aferall, I’ll be a long time qualified!

Falls Risks and Flawed Plans

Week Three

I have had a lot of reflecting to do this week. I knew at the beginning of the week that I was not where I wanted to be in terms of learning and progression. I have been anxious and frustrated at some of the ‘silly’ mistakes I have been making; by now I should be focussing on honing my clinical reasoning skills. My own self-criticism and high expectations has meant I have, thus far, been disappointed in myself and my performance. I considered myself to be fairly insightful and ‘switched on’ to where I have been going wrong. However, this week I have learned better than ever before, the value in seeking and receiving feedback. It has readjusted my focus; made me less anxious and much more likely to enjoy my final weeks in community rehabilitation. Most definitely, it will have helped make me a better therapist. Furthermore, it will probably be the single most powerful message I will receive in remembering to actually enjoy the journey. With so many tasks and deadlines ahead, at times it is easy to lose sight of what I am actually doing…and why.

Reflecting on My Clients

I am told that people seen in the community do not think of themselves as patients and as such, request in the main, to be referred to as clients. I have led on a number of client appointments this week and been happy with none of them in varying degrees. Something has always been missed; I have forgotten to check, ask or measure this or that and sometimes even been unsure why I am there. I am visiting archetypal examples of community-based rehabilitation clients; mostly older adults with advancing years and declining health and mobility. Generalising of course and every client is indeed different, but I am presented often with similar deficits, be it reduced balance/ increased risk of falls and varying difficulties with muscle weakness and mobilisation. Easy, you’d think then, to address these repeatedly seen deficits and difficulties. Yet not so, in my short and limited experience. This succintly illustrates why I have been struggling. Community falls risk and minimising hospital admissions is bread and butter stuff in community rehab. The Chartered Society of Physiotherapy (CSP) promote how useful and cost effective falls prevention is to the NHS – with stark and clear statements such as “If everyone 65+ at risk of falling was referred to physiotherapy 225,300 falls would be prevented, saving the NHS £331 million every year”. Yet with every client I visit, despite possibly sharing in common weak quadriceps, or poor balance and perhaps even hazardously arranged furniture, I am left with a head-scratchingly complex set of ‘problems’. With advancing years we increase our likelihood of multiple co-morbidities; we may be more isolated and lonely, or perhaps sendentary and experiencing increased pain. Quite logical then, perhaps, to encounter depression or anxiety and other mental health problems. With so many factors contributing to poor health and with the real increased risk of falling, it becomes difficult to separate out the issues and decide where best to start with helping someone to help themselves. It would be easy to dish out sheet after sheet of home-based exercises supported by the evidence base and bid farewell. Sometimes, this is appropriate and all that is necessary. But more often than not, providing simple, straightforward advice and education to clients about lifestyle and exercise/activity will be needed too. I have flashes of Engel’s Biopsychosocial Model when I consider all that is perhaps required to really make a difference to someone’s life. Afterall, my aim in being in someone’s home is to prevent them having to be admitted to hospital and allow them the independence they need to remain living in their own home. I am a staunch advocate of empowering people to maintain their independence and believe it is a powerful driver in keeping someone mobile, healthy and happy. My brain has been almost unravelling at times, as I listen to complex ‘subjectives’ thinking to myself ‘I cannot possibly address all this’. In turn, my objective assessments have been as disorganised as my thoughts and have felt much the same. Frankly, with such chaos, is it any wonder my findings are confused, leaving me feeling I have no clue how to treat? With much discussion with my educator and with University staff and repeated eyeball-rolling embarrassment, I am finally realising that I am expecting too much. I need to focus more on obtaining good, sound objective measures that will in turn inform my treatment choice and clinical reasoning. I am told I also need to just relax and enjoy the experience! I have been so focussed on trying to ‘fix’ everything and have probably achieved the exact opposite!? Prioritising my findings and choosing those most important to the client will surely make my treatment more successful…? So, that is exactly what I plan to do differently for the remaining three weeks. No longer will I panic at the complexity of some clients’ situations, rather I will try at least, to pick perhaps one or two key issues and address those. I may not be ‘fixing’ everything as I would wish, but I may perhaps just make a small but significant difference to someone who has been unable to leave the house for four weeks, for example. I try my best to enjoy the experience but sometimes the desire to ‘do well’ supersedes that luxury! As always too, I am perhaps in danger of sinking under the weight of the evidence-base I am trying to familiarise myself with; the NHS guidelines, the empirical evidence, the local policies and pathways…but that is another story!

Halfway Point

So, as I enter week four on Monday, I will be in receipt of my midpoint review – but I am pretty certain there will be no surprises as my educator and I maintain a constant feedback dialogue. I know where I need to focus and what I still need to do. I know that to make changes and develop I need to ‘complete the reflection loop’ – something I have be neglecting in recent weeks. I know too that I must be realistic in what can be achieved, by a student, in six weeks! For now, I will enjoy the remaining weekend ‘downtime’ and think about how much studying I should be doing for my dissertation…I work best under pressure anyway and the deadline is months away. Well, I am convinced…for now at least!

“Ground, Open Up Please”

Week Two

I am now well versed in the process of placements. I know roughly what to expect and what is expected. I am surprised, however, that those awkward moments and uncomfortable ‘fears’ which would usually visit me by week four or five have reared their head already in week two. I have made a concerted effort to keep my educator abreast of my thoughts and verbal reflections as I go along. I find it helpful to know they are aware of how I feel about my appointments and most importantly why I feel that way. This week made me particularly grateful I have been regularly sharing. I had just experienced what I would describe as an abomination of an initial assessment. My confidence had taken a massive hit and I felt angry and frustrated at how badly things had gone. We left the client’s house and jumped back in the car. As I started to explain how I felt and why I was so cross with myself my educator added some valuable new angles to the situation. Yes, it wasn’t perfect. Yes, I had missed some things. However, I was feeling these uncomfortable fears because, this time, much earlier than in previous placements I was getting ‘out there’ and challenging myself with more complex patients. ‘True’ I thought, but this particular appointment will stay with me for some time to come. Picture the scene…

The Scene

I approached the front door with confidence and clarity in my plan. I was leading the appointment and felt comfortable in doing so. Then my educator reminded me I was seeing a retired healthcare professional. “Eeeek” went my little inner voice, “I will be sussed in a flash, I am a fraud!”. I tried to gather myself and put my worries to one side, but on reflection I was by now wearing the ‘cloak of fear’. Within two minutes of the subjective, the patient was describing their symptoms like no layperson would ever do. Medical language was thrown in left, right and centre and frankly not all of it was familiar. I could sense the patient’s partner intently looking at me from out the corner of my eye. In the other eye, I could see my educator busy himself in a pile of papers in a bid to be discreet and nonchalant, but I knew I was being watched. The pressure was beginning to mount. I needed to carry out a balance assessment as a baseline outcome measure for my patient but I was unfamiliar with the one I had been recommended to use. My patient mentioned previous transient ischaemic attacks (TIAs) and sometimes found tripping up a problem. I enquired into these symptoms to clarify whether they were potentially linked to footdrop but parked the information for later, in my mind. My educator interjected at this point with a prompt to follow-up on the footdrop clues with a physical assessment of the ankle joint. Damn, I had received a prompt. I should have followed this up straight away. I am an idiot. I ploughed on, feeling an increasing sense of urgency to ‘get to the end’ of the assessment in one piece. I assessed gait, balance and various transfers and had enough findings to prescribe some basic balance-based exercises. We ventured together to the kitchen so I could impart the suggested exercises to the patient and I felt my educator lingering in the background, positioned so he was able to assess my delivery. I removed one exercise and justified why I made this decision to my educator. He disagreed and explained why. Of course, his clinical reasoning was obvious and transparent once he had explained why the exercise should stay. Again, I messed up. ‘This patient is going to have no confidence in me soon – I already have none left for myself’ I thought, as I tried my best to continue on. As I finished explaining the last exercise, the patient shared how they often did this one ‘in the shower’. ‘My goodness’ I thought, ‘what the hell are you doing that in the shower for? That is not a safe thing to do!’ That was my mistake; thinking it and not acting on the thought. I needed another prompt from my educator to view the bathroom and assess the handrails for security. Would I even get out of this house alive…? I did get out alive, but with zero self-confidence and a huge sense of failure. I was crazy mad with myself – and just when I was beginning to think things were coming together. This is where you joined my story so, by now, you know I ‘debriefed’ with my educator and gained a sense of perspective on the situation. It is true that, despite how uncomfortable and awkward it feels, these kind of experiences really do provide the best learning experiences. I can observe a qualified physiotherapist all day long in appointment after appointment and take some lessons onboard; but nothing works to cement knowledge quite like that hideous and excruciating feeling! I can hope to learn all my lessons before I qualify – but I am realistic that this isn’t going to be the case. It will be forever before I know it all…

Mental Health & Long Term Conditions

I was fortunate enough to be invited to a training session on this topic. I was fascinated in this area and it was clear how much more there is to be done to address the needs of those with long-term conditions (LTCs) such as diabetes and arthritis. Motivational Interviewing was touched upon and this further made me sure I had chosen the right area to explore for my dissertation. The basis of Cognitive Behavioural Therapy (CBT) principles were explained and opportunities to use some of these in practice were described. I had to remind myself I had a degree course to complete before I run away with ideas of post qualification courses! It did prove though, there is a wealth of opportunity out there and I am keen to get going! I duly made sufficient notes to later explore my areas of interest and joined the e-mailing list for further information.

Looking To Week Three

My hope is that next week starts better than the last ended. I know it is unrealistic to expect everything to go swimmingly. I also know I am perfectionist in my attitude and anything less is a disappointment. I am well aware how many more disappointments lay ahead but I am OK with that because it means I am heading in the right direction. Each mistake is a lesson, each lesson makes me a small step closer to where I want to be.

New Year, New Directions

Week One

As the new year began, so too did my penultimate clinical placement. Refreshed from the Christmas holiday unwind, I felt ready to face the challenges that lay ahead. I have been placed within a multidisciplinary team (MDT) out in the community. I will be working alongside Occupational Therapists (OTs), nurses and rehab support workers. Our joint aims are multifaceted; to prevent unnecessary hospital admissions, to facilitate timely discharges, prevent falls, manage long-term conditions and prevent premature admission into long-term care. The geographical area covered is vast and often rural, presenting challenges of its own. The trust is large with three separate Clinical Commissioning Groups (CCGs) and this week provided me a valuable opportunity to witness the challenges facing staff working in this area of physiotherapy.

Generalism As A Specialism

It has struck me this first week how skilled a clinician needs to be in just about all aspects of physiotherapy in the community. From stroke, Parkinson’s Disease, fracture rehabilitation, chronic respiratory conditions to dementia care, falls risk and Multiple Sclerosis – neuro, MSK and respiratory skills are all called upon to effectively manage people within their home environment. It has also been quickly apparent how valuable it is to see someone in their own home. Unlike in the hospital setting, where only specific questions are asked regarding such things as access to the property and stairs, when visiting someone in their own home you can actually witness what they struggle with and how they manage day-to-day activities. It also affords you the chance to make their rehabilitation functional, specific to them, and using equipment around their home to assist. I was initially fearful of how wide the scope of practice would be with such vast differences in the conditions I will be treating. However, it is already clear that provided a thorough assessment is carried out it is relatively straight forward to provide goal-led personal care plans for people – it is also clear that many of the people I will be visiting have complex needs that can be addressed properly only with the input of many professionals within the MDT. I am excited about the opportunities this placement will provide me with, calling on me to use all aspects of my skills set sometimes all within one morning.

 

Public Sector Problems

I have had previous experience of working for a public sector organisation going through structural change from a governmental level. I know too what it can mean to face the risk of job loss through privatisation of services and the process staff can face under the transfer of undertakings/protection of employment (TUPE). It was very interesting for me, therefore, to bear witness this week to a ‘competitive dialogue’ workshop aimed at addressing some aspects of the procurement procedures involved when services are put out to tender. It was clear that real challenges lay ahead in the modern NHS, that no service or provision is ‘safe’ and everyone has a responsibility to ensure innovation of service if the NHS is to survive. It also gave me a better sense of contextual relevance to ‘elevator pitch’ tasks I had taken part in at the PhysioWorks Locally event I had attended back in November 2014. I must confess, as I begin my final furlong into a new career in physiotherapy, I am somewhat concerned that I am moving from one problematic public sector career to another. Then I remind myself there is one fundamental difference; I have a real passion for the physiotherapy profession and love what I have been doing during this degree course. My previous sense of disillusionment was borne out of low job satisfaction, poor staff morale and apathetic management – none of these aspects seem present in any of the areas I have been placed in and I am confident and certain pursuing a career in physiotherapy is right for me, though I am realistic about what challenges I may face in the future.

Planning For The Weeks Ahead

I am aware that as my confidence grows in my own clinical skills, I have new freedom to explore other areas of the profession. I cannot imagine just a matter of months ago, within my first placement, having the capacity to think critically about such things as the NHS organisational structure or the performance of the trust that I am working within. As I creep ever closer towards the ‘dreaded’ employment search after graduation, I become more aware of these aspects and their potential influence in my decision-making process when it comes to submitting job applications. Whilst the task ahead of completing my degree in the next few months seems to be no mean feat, I am beginning to feel restless and eager to reach the end. Dare I say, I am, perhaps, even experiencing the first real sense of feeling ‘ready to go out there’ and be a bona fide junior physiotherapist. All rather well and good considering that in less than six months that will be the case! These final placements offer me the opportunity to consolidate my learning and develop as much as possible before I reach the point of ‘stepping out’ into the real world. These blog entries allow me the chance to reflect on my progress critically and keep me aware of my own learning needs. A rather useful process frankly, to ensure I gain the most from each day on placement.