Well it’s finally come!  My placement ended on Friday and funnily the last few shifts have been the calmest since I’ve been on the Ward!  Final sign-off was a bit of an exercise as I needed to get my document counter-signed as my mentor was out of date.  But it was all completed on Thursday and this morning I submitted my PAD/OAR to the SHS Helpdesk.  So now I wait to find out for confirmation that my placement hours and work are acceptable.  If I’m unlucky, I’ll be repeating the process in a few weeks.  But lets not think about that!  Killing time now as we have some closure lectures and activities at the University which begin in half an hour!

So what does it feel like that I’m finished?  In the last few weeks this theme was explored at PPD and in conversations but until last Sunday, as I went into my final week, I hadn’t really thought too much or felt anything at all.  As I dosed off last Sunday though, the thought that crept through my mind was, “Wow, three more shifts and you’re eligible for registration with the NMC!” , or thoughts to that effect!  I think sometimes, I just plow ahead and do things or become fixated on completion – I had forgotten about GOT, which shows how focused I’ve been!  With my PAD/OAR handed in I’m more forward looking and beginning to do some background work on the care of the elderly which is where my first acute rotation will take place.

Reflecting on the last 4 years … It’s been generally good.  Hated my second year at University, a lot of things unravelled in my personal life which reflected in my grades!  Placementwise it was brilliant as I got my first taste of Psych Liaison but also saw in a private hospital what would could be classed as the Dickinsonian treatment of women with mental health issues.  We are the sum of our parts the experiences that we live and the latter point helped fuel my Dissertation.  This final year has seen me at my most wishy-washy, not feeling the love with older adults than really enjoying it later on, to the point that this is where my first job will be based!  This last placement has been brilliant as it helped hone my ward based skills, so I’m feeling pretty confident going into my new job.

Quo vadis? … I’m going to be spending much of August working with my dissertation supervisor exploring whether we can convert my dissertation into a published article in an academic journal.  In parallel with this will be paid shifts across ELFT as I try to get my finances in order for holidays in September.  As mentioned, September is the celebratory holiday – booked a few days out in Budapest with the other half, and in the planning for a walk in the woods by myself.  Than its my first day at CNWL on the 2 October!  I may be back here to talk about my first year of work but if I don’t, its been a pleasure and I hope I have helped tipped the scale and I’ll see you on the Wards!

OK, we are almost there!  Since last I wrote here I have had my OSCE result back, clear pass, yippee!  In OSCEs you never know, you could forget the tiniest of things and it could have been the critical skill that causes you to fail.  Luckily for me, it’s all over and now I just get to do it for real 😉 … The other item on the tick box was my dissertation, the piece of work that caused me endless sleepless nights!  Results are back and I did well on it and there may be potential to take it forward to publication.  I’ll know a bit more on this in a few weeks when I have a sit down with my supervisor to see what needs to happen next.

So this just leaves my final or signoff placement at the PICU before I say good bye to this phase of my development.  So what is this signoff placement about?  In mental health it revolves around you transitioning from the student role to that of the RMN.  On my shifts I am either coordinating or medicating!  … Just kidding, its much more but activities do span these two key duties.  Thus on a typical shift in the coordinating role, the aim is to take the handover and identifiy any risks to staff or patients for the day ahead.  What are the risks?  In the PICU some of the patients, due to their illness, may span the spectrum from vulnerable to violent and what the coordinator needs to do is ensure that these risks are mitigated by ensuring staffing levels and allocation to patients is appropriate.  Further, care plans are being done and are not some words on a piece of paper and dynamic updates to care plans are made throughout the day via the “safety huddle”.

The other side of the coin is the medicating of patients.  One of the key roles of the PICU is the stabilisation of patients and in psychiatry this is achieved primairly through the use of antipsychotic medications.  Often patients in a PICU may be presenting with psychosis for the first time in their life and may be naive to the effects of these types of medicines.  Thus as a medicating nurse, and as a nurse in general on the ward, there is a duty to monitor the advent of any side effects which can range from oedema of the feet through to death in the most extreme of cases.  Additionally as the person responsible for dispensing medications, you are the last check in the case of an error being made on the prescription.  Thus one of the key skills is an understanding of maximum doses in a 24 hour period, contraindications and interactions.

Standing between these activites is a range of tasks which supports the stay of the patient on the ward.  This could be mopping up urine from the floor (something I was doing at 4am this morning!) or having a one-to-one with the individual you have been assigned to for the day.  On the administrative side there is the admission paperwork and discharge paperwork to complete; care plans to write or update; and the referrals to make on the paitent’s behalf.  In the global community of London there is often the booking of translators and the “googling” of cultural informaiton to help make an individual’s stay on the ward a bit more personalised.

So what’s left for me?  I have one more shift this week and 3 more weeks (or nine shifts) before I need to hand in my PAD and OAR on the 24 July.  Once those are in and there are no issues to remedy, that’s it, I’m done!  So wish me luck in this final stretch and I hope to have my next entry shortly after I drop off my stuff on the 24th!

So what’s happened since the last post? … In my mini list I’ve ticked off two more items.  I did my final OSCE, which was a teaching one.  I had a 1st year Children’s Student Nurse and the aim was to teach him how to do a temperature reading and measure pulse.  Results are back in and luckily I passed – I didn’t do great but as they say, a pass is a pass!  My reflection on this is I hate the exam environment!  I know I didn’t demonstrate the teaching techniques as well in the exam environment as I’ve done in actual practice!  It makes me wonder whether the teaching OSCE should be moved out into the practice environment – this is currently done in the post-grad nursing course.

On Monday my dissertation was submitted and it felt like a big fat monkey was no longer on my back!  My dissertation in a way marks my progression through the issue of women’s mental health.  My first ever Ward based placement was on a women’s ward and since that time I have seen the ever increasingly evidence for gender specific diagnosis and treatment.  My journey towards my topic choice was an ever winding one – initially I wanted to look at how menopause effects women with an existing diagnosis of bipolar disorder.  Due to the paucity of good, recent research this topic became, how menopause could be a trigger for the onset of schizophrenia/bipolar disorder.  Then following my placement with the RAID Older Adult team, it looked at menopause and the longer term impact on women’s cognition and dementia.  Until finally my topic became an examination of whether hormone therapy could serve as an effective treatment option for menopausal women who had depression.  Guiding me on this journey was Professor Salmon, who helped ground my ambitions to a topic area that was realistic for this level of study.  For prospective students, this is one of the benefits of City – you get to explore an area that has great meaning for you and are provided with supervisors who span a multitude of areas and are recognised often nationally and internationally in their specialities.

Into my third week now on the PICU Ward.  It’s proving to be a brilliant environment for making me into what I hope will not only be a competent mental health nurse but also a good one.  One of the major points I’ll take away from my time at City is best summed up by my OSCE Lecturer of the last three years, “What type of nurse do you want to be?”  In the ever changing workplace with diminishing funding and increased pressures on staffing often the point of why we do this role is lost and we forget that its about the patient/service user.  In a way I couldn’t find my balance in my first two weeks of practice and took this to the PPD session where we discussed how best to manage this nursing dichotomy – the need to provide person centred care but also undertake a mountain of administrative work.  This week I was able to achieve this by creating fixed time periods where I did one or the other type of tasking – in this way I was able to get the paperwork filled out but also had some quality one-to-one sessions.

For me and my nursing degree, “the end is nigh!”  In February I went for an interview and was offered a job.  The final confirmation came through at the beginning of this month, so in October I’ll be starting my new role at the Central and North West London Mental Health Trust.  It’s the only job I applied for and while I did give a lot of consideration to the trust I train in, on the balance the development programme offered by CNWL was critical for my final decision.  CNWL provides an 18 month development programme which I believe will assist in my transition from the student role to that of a staff nurse.  As I write this I wonder why more Trusts don’t make a similar investment!  It’s been a bit of a slog and at times I wondered why I walked away from one life to enter this one but at this time I am seeing beyond the horizon and it is looking good!

New milestone …  Last Monday I put in my first application for a job!  Well not exactly my first application ever but my first for my future role as a RMN!  I’ve been looking at jobs advertised across London and the one I’ve put in for is for what’s known as a ‘rotational programme’.  This enables you to spend time across different mental health areas in your first 18 months of your career before you settle down and begin specialising in a specific area.

The application process is similar to your UCAS application – you have to write a ‘personal’ type statement but it is focused around you demonstrating that you meet the core requirements for the job.  Best advice I have received about how to do this, is to remember to put patients at the centre of the application and show how you have demonstrated exceptional care to them during your placements.  So fingers crossed, if my application is successful I’ll be invited to an assessment day.  The assessment day is very similar to what your University selection day is like – maths and English tests; patient care planning test; group interviews and individual interview.  The good thing is they will tell you on the day if you are successful.  My second application will be to the Trust where I currently train.  I’ll try to keep you in the loop as to how these applications fair and any lessons learned through the process.

I can’t do an entry without throwing in an acronym – this week’s is DaD!  DaD stands for Dementia and Delirium (team) which are small specialist teams at Bart’s Trust hospitals – the Royal London; Newham; Barts and Whipp’s Cross. In my current placement I have been able to do some shifts with the DaD team which has allowed me to view another perspective on care offered to the elderly. The teams are drawn from staff with a mixture of general and mental health nursing experience and as their name implies they focus specifically on Dementia and Delirium.  The DaD team works with the wards to tailor care plans to help staff, patients and families deal with these conditions during a hospital stay.

On Friday I reach the half way point of my placement with the RAID team and will say good bye to the Older Adults group.  It has been a massive learning experience especially in the area of cognition and how we measure it … ACE III, MOCA, BAMSE (sorry couldn’t help but through a few more acronyms your way!) … Overwhelmingly, this placement has been quite humbling as I have worked with people who have made this area their vocation and are responsible for the care of some of the most vulnerable people in our society.  So good bye and thank you as I have learnt a lot that will influence my future practice positively

Roll on A&E on Monday …

For those of you into acronyms, here’s a new one – RAID.  It stands for Rapid Assessment Interface and Discharge, or in old-school speak, psychiatric-liaison.  I am doing my penultimate placement with the RAID team over at the Royal London Hospital, based with the older adult sub-team.  If you read your Metro, Evening Standard, or watch the news, you will see similar stories on the ‘winter crisis” in A&E – I’m seeing how this translates on the ground!  The big thing in the elderly are the 3Ds, Depression, Delirium and Dementia and the wards are full at this time of year with older adults who may have fallen over and now are at risk of the 3Ds or may have been admitted with symptoms of any of them.  Its a lot of hard work for all the different clinical disciplines and others such as social workers and a wonder to see when all the moving parts ‘click’ together!  My current placement is proving to be one of my most enjoyable which in a way has seriously surprised me – I am still trying to understand why! Could it be the great staff I work with; the environment; the outcomes?  Still trying to piece this together and will share at a later date.

For those of you going through the application process, you have hopefully met the UCAS deadline.  When I did mine, I remember there was a bit of a pause before the Universities kicked the ball into action.  This is probably most applicable for those who are going through the Access Course/non-traditional routes.  Bear in mind that often, no news is good news!  So a few tips for you – get as much maths prep as possible – look up the SNAP site, especially if you think you have a problem in this area and just keep doing questions.  One of my observations when I went through the process was many of my class mates falling at this hurdle.  So what next?  Be yourself!  If you get to the interview stage, seriously, just be you?  Don’t try to second guess the interviewers and portray an image of who you think they want.  If you can’t answer why you want to do nursing, seriously, should you really be engaging in this process!  So be honest, if it’s because of an experience or your beliefs, just say so!  It might make sense practicing on your friends or relatives.  Also be honest about your experience, don’t exaggerate, the interviewers have been on the shop floor so have an idea of what really happens out there.

If you get multiple offers what do you do?  One of the things I tell potential students at City Open Days is that they need to weigh up a lot of different factors before they make a final decision about what Uni to attend.  The NMC specifies what is taught on nursing programmes so there is not to much difference in the course no matter where you study.  More importantly, in nursing we spend over 2000 hours working on placements and what we gain here is an opportunity to learn best practice from actual practitioners.  Thus look at what NHS Trusts your potential universities are associated with – for mental health at City it is the East London Foundation Trust (ELFT).  Next look at how it has been rated by the NMC – in ELFT’s case it has achieved an outstanding rating in 2016.  Look at patient forums and how they view the Trust or, in most cases how they were treated at specific hospitals or wards.  After you have done all of this, than you have a better idea of how whether you will get the best out of specific institutions.

On a separate issue, this weekend marks the Chinese New Year, thus if you haven’t kept any of those New Year’s resolutions, here’s another opportunity to reboot!  For those who are wondering, it’s the year of the Rooster – if you can divide your age by 12 this year, its likely that this is your sign.

I’m on ‘holiday’ right now and wow, it’s all over! No, not my course but the taught component.  It’s took a while coming and then bang, it happened, my last ever lecture for the course – a lecture on critical analysis for the nursing dissertation took place last week.  How do I feel? Elated? Nope, surprised is more like it!  I hadn’t even realized this milestone had crept up until a colleague mentioned it and gave me pause for thought.  Now I’ve got to get down to it and deliver two pieces of work in the new year!

So what’s left?  I’ve got an essay on management and my dissertation to hand in, one for March and the other for May.  It’s off to simulated practice for a fortnight in January – this as its name suggests is a simulation of what we face on the wards and a refresh of clinical skills.  It also serves as a preparation for the final objective structured clinical exam (OSCE) which this year revolves around teaching skills to a first year student.  And there’s twenty-two weeks of placement – 10 weeks in A&E with the Royal London RAID team and 12 weeks in a placement still to be determined but hoping it will be PICU (an area I haven’t done a placement in as yet).

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As I mentioned in my previous post, I want to talk about ECT, electroconvulsive therapy.  For those who have not heard of this form of treatment you may have heard of it crudely mentioned as “electric shock” therapy or been referred to “One flew over the cuckoo’s nest”.  In my long distant ‘youth’, my understanding of mental health and illness was defined by the 1975 movie,”One flew over the cuckoo’s nest”.  (Spoiler alert – if you want to watch the movie) Two things have always stood out for me from this movie Nurse Ratched (who is overbearing and imposes her values and views on her patients, lacks compassion and empathy and causes the suicide of one of her charges) and ECT (turning Jack Nicholson’s character into a drooling wreck).  It is only recently that I learnt that Nicholson’s character wasn’t affected by the ECT but rather had a lobotomy which is what left him the ‘drooling wreck’.

Becoming a mental health nursing student and undertaking my placements has shown me that there is no role for Nurse Ratched’s in this profession.  Yes, I have come across the occasional person who aspires to be her but overwhelmingly staff are supportive of service users and often go the extra mile to get people well and resuming their lives.  Thus destroying this stereotype in my mind!  However, my views that ECT leaves people as gibbering wrecks remained until recently.  So what is this ECT thing?  In a nut shell it revolves around sending a small electrical charge through the brain which causes an epileptic seizure.

ECT was what mental health was about between the late 1930s through to the 1970s where it was used for a variety of mental illnesses but especially depression.  Thereafter we see it decreasing as a primary treatment option and the emergence of medications.  Over time clinical evidence suggests greater efficacy of positive outcomes with medications and overall there has been a decline of ECT to the extent that it is rarely used.  So why is ECT still being used?  These days ECT is used as a tool of last resort, NICE (2009) guidance sets out “ECT should only be used for the treatment of severe depressive illness, a prolonged or severe episode of mania, or catatonia…” Having seen it in ‘action’ it is not a pleasant experience to witness but it does provide the service user with an ability to resume their lives in a scenario where this has failed through other routes.  And again a lot of this ‘success’ rests with the professionalism of the staff undertaking these procedures.

This is it for this year, so have a wonderful time and we’ll catch up in the new year!

One of the major ‘tools’ of the trade is reflection.  Reflection in its purest form is about looking back at an event and evaluating it.  Gibbs (1988) is a reflection model widely touted by tutors, however my preference is for Driscoll (1994) which simply asks: what, so what, now what?  The reason I bring this up is that the nature of the course is that the NMC requires 2300 placement hours, at City you often do in excess of this requirement.  In this setting you will come across situations you have not covered in the classroom or simulated practice and this is where you apply reflection in order to achieve the greatest learning outcome.

Ok, boring so far? I remember when I was introduced to this whole concept, I was “Yeah, yeah, yeah!” but reflecting (see, got that term in again) on it I now realise how invaluable this has been for my mental health practice and maintaining my personal equanimity.  On a mental health ward you are often presented with the raw emotions of the patients which can range from sadness, to elation, to anger.  And sometimes these could be directed at you.  As someone to whom mental health issues was a foreign concept, until recently, this could prove overwhelming.  Thus your lifeline, for your personal mental health, is often deconstructing the ‘incident’ using the reflection model.  On countless occasions it has allowed me to take away my personal emotional response and bring it back to where it matters – how can I best help the patient?  At the end of the day we need to remember that we are here to support people getting back on track with their lives even when their behaviour to us would not be acceptable outside of the ward.

The second lifeline that you have as a mental health student at City is the PPD.  Officially it’s Personal Practice Development, but we all call it “the PPD”.  Some of us in the cadre hate it and some see its merits – I’m in the latter category.  So what’s this PPD stuff about?  A PPD group comprises up to 10 fellow students with two lecturers acting as facilitators.  What do we do?  During placements we primarily discuss our emotional responses to different situations which present themselves on the ward.  Part of the problem with working in mental health, especially if you are new to it, is that you are often holding onto emotions which are often not yours.  PPD has often provided me with that opportunity to offload what could become a debilitating response or one which I could take home to the detriment of my loved ones.

So what am I getting at in this entry?  Working in mental health is not to be entered into on a whim.  It is a serious proposition which not only has an impact on those we care for but also, on you as the practitioner.  Overall, don’t fear it as like me part of the process is equipping yourself with the ‘tools’ to become an effective practitioner – something City and ELFT do quite well.

I hope you have enjoyed my entries thus far if you leave feedback or questions I’ll try to orient the next post as a response.  Barring that my next post will cover controversial practices – covert administration of medications and ECT (look it up or wait for the next post).