too many supervisors

I am on prac at the moment and we have three supervisors each week, and things are becoming a bit confusing. I realise that every physio is different and they treat patients based on personal experience. But the problem comes when you learn something really great from one supervisor and think you are on the right track, only for the next supervisor to come along and ask you why you are doing something a certain way. This has happened a number of times. I was treating a patient with another student, and we were practicing sit to stand with the patient resting one arm on a large bolster to encourage him to make more use of his lower limbs during the task. Things were going really well, and the patient was happy with how he was going. One of the supervisors then came along, and right in front of the patients asked us to explain the rationale of using the bolster. When the other physio had explained it and had been using the bolster, it made perfect sense to us students and the performance of the task looked pretty good. The second supervisor then went on to explain all the reasons why we should not use the bolster. We did not want to say that the first physio had suggested we use it, because we did not want to sound rude. So we carried on the treatment session without the bolster, and the patient really struggled for the rest of the session. In my personal judgement, it gave him a sense of security knowing the bolster was right there in case he lost his balance, and once it was removed he really struggled to complete the task well. Due to this fact, extra load was placed on me and the other student trying to facilitate sit to stand and I needed the rests more than the patient.

This happened two or three other times last week, and I am feeling a bit confused. Who do you listen to? I have not spoken with any of the supervisors about this because I know they will just say that its all a matter of personal choice. But then isn’t it also our choice based on our capabilities as students. Is it not fair that we choose the option that we feel most comfortable with. I have spoken to another student who had this same prac and she said she experienced the same problem all the way through her prac. I think it probably wouldn’t hurt speaking to one of the supervisors at some stage and just voicing my concerns, just so that they are aware that I am willing to try different treatment options from all of them, but that we just may vary which ones we use. The other student and I have also decided that we will choose techniques based on which supervisor is there, and be able to rationalise why we are changing if we decide to do so.

Patient presence... and presents?

On my rural prac, I was treating a male outpatient for shoulder pain. On my initial assessment, he came across as a very friendly man and we chatted throughout the session. I was trying to be polite and show an interest in his hobbies etc. On the second session he was much more open, telling me about his life and interests and asking about my life and future plans etc. While still taking the conversation quite lightly, after the session I began to question whether it was apprpopriate for him to go into so much detail about his life with me. I brushed this off and just thought if he needed someone to talk to, there probably isnt any reason why it cant be me and that he was probably just trying to be nice to me as I was still very new to the town.
I was still a little unsure as to his intentions in the third session, but told myself just to listen passively and not reveal too much about myself in any answers I gave. At the end of this session, he gave me a gift of a CD which we had discussed and invited me to come and watch him and his band play on the weekend. I tried to politely refuse the CD, but he insisted I take it and just put it on to listen to in the office if we wanted. Thankfully I was able to think of a quick excuse as to why I wouldnt be able to go and thanked him politely for the offer.
This situation made me feel really uncomfortable as I was still unsure as to whether he was just being genuine and friendly or if he had other intentions. It made me realise that while it is good to build rapport with patients to earn their trust, you should have a definite 'line' set in your mind about what does and doesnt make you feel comfortable and to advise the patients of this should they approach this line.

OT vs PT

I've never really understoof why there is sometimes this rivalry between OTs and PTs. I went to China to work in a childrens rehab centre with 8 other occupational therapists. To be honest some of them had no idea what a physio does and just assumed I would be treating the patients with massage! Throughout my previous placements this year I tried to make an effort to recognise what an OT did because I didn't really understand their role. I attended my patients OT and speech sessios and began to become familiar with what my patients did outside of the physio and medical management. So i was a little bit offended that the OT students weren't familiar with our role because surely they had been exposed to a bit of it during their placements this year. Anyway on the trip I realised how well the two professions can complement each other. For example I would work with one of the children with another OT student. I would focus on the posture/positioning and challenge the child this way, whilst the OT did some UL work.
It made me realise that we shouldn't be so stubborn about our roles and who does what.
Working together, made the session so much easier, the child got more out of it and you could bounce ideas off each other to make the task more challenging etc.

family members..

On my placement at the moment, I was treating a patient with my supervisor in the gym. We invited his wife to come along to watch so that she became familiar with the activities that she will be doing with him once he is discharged. Throughout the whole session she would speak for her husband and say things like the poor baby can't stand up it will hurt him. She would also interfere during the session by helping her husband with the activities/exercises even though he was perfectly capable of doing them independantly. We decided that the next time we brought the patient to the gym for treatment we would tell the wife that it was now protocol that no family members are allowed in the gym during treatment session. She was compliant with this but still hovered at the door watching. Luckily for us, this patient was very motivated and willing to do anything we asked him so minimal education/motivation was needed for him. Most of the education was directed at the wife to ensure the patient becomes fully independant at home.

This situation made me realise how important family members are to the patient. Sometimes however you have to be strict on visitors because they can impact on treatment sessions and the progression of the patient's function.

Trying different approaches

Whilst on my rural prac i had the oppertunity to explore some different methods of communication and also treatment strategies with patients. A patient that started attending the clinic was a young girl with a history of chronic lower back pain approx 75% of her life sofar. From an early age she was told be her doctor that she had a serious back condition (as seen on CT scan- which was actually just a sacralisation of L5. A condition that has no significant evidence to attribute increased LBP). This developed into a very heavy fear-avoidance cycle where she was not going to school very often, not doing any physical activity and not working.
One of the senior physiotherapists started treating the young girl but with very limited results both emotionally and physically. The young girl then got handed to myself to treat and i got told to try some different approaches.
Being closer to the age of the patient i was able to develop really good rapport and achieved some drastic emotional and physical results. Initially we developed an exercise program that we would both do together. The rules for this program were that we were not allowed to mention her back pain (unless it increased significantly during) and that we would do the program no matter how she was feeling. I was able to use conversation and lots of distraction techniques to stop her focusing on the back pain. One of the biggest break throughs was when she started to understand that even if the back is sore, if exercise doesnt make it worse then its getting better!

This is a very long-winded example of how utilising different treatment approaches can be very beneficial, expecially in chronic conditions. Also, its an example of how we should not be afraid to refer to a different therapist if we are not getting the results/rapport that we need with a patient.

Juggling placement and curtin tutors expectations

Whilst on my last prac i had some definate difficulties satisfying the expectations that the placement and the curtin supervisors wanted. This wasnt because i was not competent and was not satifying the workload, it was for a different reason.
Whilst on the placement i was expected to work independantly with my own patient load and treat the patients as the other physiotherapists were. This consisted of quite short and very functional treatment sessions where you go in, address a problem and then leave. This approach worked very well in this scenario as it was a private rehab ward.
The difficulties arose during the 3 hour per week curtin supervisor period. As part of the prerequisite to demonstrate my competence i was required to assess, treat the impairments, treat the functional tasks and write-up goals and show how these goals were progressing. This approach required approx 1.5-2hour session with the patient. This would have been fine if i had the oppertunity to practice this approach during the week.
It turned into the most stressful prac because i was being assessed on things i havent had the oppertunity to practice in full. When i talked to the tutor about this, the solution included full write-ups for each patient. This made it easier but meant that every night i was knee deep in paperwork for each patient.
I got through the placement alright but it just emphasises the difficulties that arise when the placement and clinical tutors are on completely different wavelengths!

You know more than you think.........

My last clinical placement was with community physiotherapy services and on this placement I had to run several exercise classes. This was fine and I had no problem planning and executing the classes at the right level and achieving what I had set out to schieve.

The most important aspect of the classes I did have to work on....... the education segments........ I got some great advice from one of the physiotherapists that I was working with and it was 'you know more than you think you do'. By this she meant that we as physiotherapists (even us as students) have aquired a large amount of information over the last 4yrs, even though we may not think so. The general public are not as well informed. Her advice to me for my classes was to just throw in various pieces of advice as they came to mind, even if I thought that everyone in the class already knew the information I should just say it as it it would be more than likely that most people did not know and even if they did a reminder is always a good thing. Just as an example posture, everyone knows that they should maintain a good posture but how much do the general public actually know about how and why they should be doing this???

I just thought I would give this advice as I have found it very useful not only for exerise classes but for individual treatment sessions as well.

Clinical Tutors

Through out the year and through all of my previous placements I have not had a problem with anyone of my supervisors and so have never really had to deal with conflict of this sort. Whilst on my last placement I had several supervising physiotherapists which soon began to take it's toll as each of these physiotherapists had thier own preferred method of doing things and ranked the importance of certain tasks very differently. There was one particular physio who I just could not seem to see eye to eye with. I only had a chance to deal with each physio once a week and even though I would implement the changes in my sessions as she had requested but I was getting conflicting advice from other physios and I felt as though I could do no right in her eyes.

This eventually began to stress me out quite badly. My curtin supervisor came to assess me whilst I was with this physiotherapist and commented on the difference between this class that I took and the others that I had taken, she was worried because the class that I had taken was not up to the standard that I had set with other classes. I had not yet spoken to her about my 'conflicts' with the physio as I had only seen my curtin tutor on two occasions previously and did not feel that I could tell her of my problem. Luckily for me she picked up on it and her and I sat down and discussed strategies to manage this. It was just a matter of conflicting personalities, she also encouraged me to just back but the reasons why I was doing what I was doing as the phsyio would respect this more.

From this I realised the value of our curtin tutors, not only for promoting and developing our clinical knowledge but for a range of other problems that we might have. If anyonelse has any difficulties on their placements I really would recommend discussing this with your tutor. They are here to help us through to the end of our physiotherapy degree so just ask for help if you need it!!

chronic pain

While on my rural prac I encountered a chronic pain patient for the very first time. He was a middle aged man who had a 10 year history of lower back pain, which resulted in him quitting work and being on workers compensation for a very long time. When I first assessed him, he was very specific about where his pain was, and on physical examination I was able to establish some problems which I could treat. However, with each visit he made more and more problems became evident, and he kept remembering more things that he couldn’t do. So I became quite confused, even though I realised he was a chronic pain patient, I just wasn’t sure what exactly to do.
So I spoke with both my supervisors and they gave me a lot of education on chronic pain, because I feel this is an area we don’t get to spend a huge amount of time on in class. They educated me on the best management strategies for him, and that hands on treatment would work short term but he needed longer term management. So when my patient came in again, we spent the whole session just talking. He asked me why I wasn’t `treating` him as he always felt 99% better after treatment. I explained that he needed a much broader approach to his pain. I booked him in for hydro sessions, which he absolutely loved and which helped to keep his pain well under control. We also managed to address other issues in his daily life which may have been affecting him. The end result was a very happy patient who I felt happy to discharge from physio as I knew he had taken everything on board and would manage fine. After all the help and information from my supervisors I feel much more able at managing patients with more chronic pain now and will take the same approach as I did this time but modify it for each patient

very sick patients

Whilst on my cardio prac, I encountered a very sick 78 year old man who really challenged me. He had been admitted after NSTEMI and had had a CABG surgery. After this he was in intensive care for a few days longer than normal due to lots of complications. When he was finally admitted to the ward he was so badly deconditioned, and adding to this was the fact that he had to be on daily dialysis. So I started treating him and was able to help him clear his chest quite nicely, but I was not able to get him to ambulate. He would just tell me he was far too tired, and sometimes I would convince him to just take a few steps up and down the room with me, but other times he would just refuse. However, when my supervisor came in, he would agree with everything. So over the time he spent in hospital, he developed a pneumonia on top of everything else, and I felt really bad seeing as he was my patient.

This man also became very depressed, and started showing signs of some sort of neurological insult, but we were not quite sure what was going on and he was having head scans the day I left so I wont ever know. But I just felt that he was very untrusting of me because I was a student, and he would always comply with my supervisor. I also had times where I felt so bad going in there and waking him up for physio as he hardly slept during the night so I felt like he really needed any sleep he could get.

I spoke with my supervisor about it and she helped a lot. She said that with time you find out which patients are really really sick and those are the ones you back off on a bit. But you also learn how hard you can push someone within the limits of safety, and that this was a clinical judgement skill that would come with practice. She also said that unfortunately some patients just did not feel safe in students hands, and that was just a personal thing. And she reminded me of how much success I had had with my other patients and said that even for her there are some people she hasn’t had great success with. So in future, I will always talk over difficult patients with my supervisor along the way so that they can give me any handy hints for increasing patient compliance as a student. And I have also realised that in time I will be able to know which patients I can push a little harder than others.

Patients who go on and on and on and sing…?

Over most of my placements I have primarily dealt with older patients and I’m sure all of you know… most older patients like having a personal physio student to talk to. Especially in the big hospitals where the nurses, doctors, physios and other health professionals are so busy and only have time to do the required job. On my cardiopulmonary placement this was set to extreme. I had group classes who would primarily talk in the classes rather than do the exercise, single one on one outpatient sessions where they would stop in the middle of a six minute walk test to talk to you and then when I was in the hospital inpatients would jump at the chance to tell you their exciting news that they “opened their bowels finally today” whilst you were trying to get the subjective done. One particular patient loved to tell me about his bowels, his pains, his life stories, his beliefs on God and the general meaning of life. On the first session he complained about all the staff, his breakfast, his lunch and.. that he hadn’t opened his bowels which made him sleep badly. I managed to get a treatment in, in double the usual time. I asked my supervisor what I could do and she told me I had to be firm and realise they don’t get angry if you interrupt them. The next day I was all set to be firm and interrupt and ask closed questions. I managed to get him out of bed, he talked a little bit when walking but up until when I was about to go I was very proud of myself… that was when he started passing on his heartfelt wisdom to me ending in none other than a song. I was literally mortified that the patient was singing for me and just stood there trying to not let my mouth stay open. Afterwards I quickly thanked him and hurried off (having missed morning tea) to the next patient. A few days later I was asked to treat him again and decided I needed to think smart this time. I devised a plan to see all my other patients, write their notes up and then see my singer 15 minutes before lunch. Saw him treated him, took him for his walk and with expert timing got him back to his bed right as his lunch was being served. I said to him he did very well today and deserved a good feed which he sat down, said thanks to me and got stuck into his lunch. Moral of the story, interrupting them and moving on to each task quickly works fine to stop the life stories, however clever timing and food works best. And if you do actually have the time, listen to them as I must say, some of his stories were actually pretty interesting.

reading notes

Obviously before treating a patient, reading their notes is one of the most important things to do. One thing I have often done in the past, especially if a patient has been admitted for a long time, was to glance over their history and pay the most attention to the newest issues at the end of the integrated notes. I have learnt on my prac at the moment, that taking the time to read the 'old notes' is just as important as the new ones. By just glancing over the patients older notes, you may miss important facts about surgerys, states of instability and their general pattern of treatment/management since admission. Although it takes a pretty long time to read notes (for me anyway) its so important to get an overview of how your patient has been going since their admission, no matter how long it is.

Prioritising so that safety is put first

Whilst on my RITH placement I initially found it hard to get used to the different environment set up (the massive increase in safety risks and things that could go wrong), the lack of senior/specialised people to solve the problems for you and the fact that no matter how easy the referral looked, the patient would always have more than that one simple problem.

Eventually I got used to going to peoples homes, I improvised by using a couch or bed and learnt to kneel down or get onto their bed nice and close, NOT try lean over and politely avoid going on their bed (most clients didn’t care if you asked first). I used paths around houses to get the patient to do their walking and ganged up with daughters, sons and spouses to get the patient doing the exercises and taking the precautions. Basically I learnt to do it with just another physio student and our two inventive brains. But for some reason I wasn’t planning my sessions perfectly enough for my supervisor, I would try treat their problem as a physio, for example if they had gone into hospital for a fall I would be positively itching to test muscle strength and balance and ROM…. But my supervisor kept pushing that as a RITH physio you have to go safety in the home/functional first and in subjective, you have to ask OT and social worker related questions which I had no experience with before. It took me quite a while to get this right where I wouldn’t panic inwardly and waste time if the person had dizziness problems or multiple falls or COPD (I had just come from a COPD community placement) that wasn’t on their transfer list and feel the need to fix those problems on the initial visit.

I finally got a set up in my mind where you check their function and safety around the house (walk around with them and watch them get in and out of the shower and on and off their toilet, bed and chairs) no matter how silly it feels asking them to do it. Then you go all gun ho with physio treatment/assessment with the time left and on that first session decide how you are going to discharge.

I now have firmly implanted in my head, when you have a set schedule and traffic to deal with, how to prioritise right after your subjective, on the spot. It doesn’t matter if you take a few minutes to do it and there’s that awkward silence while you write something down and sort everything out in your head. The only thing that matters is that you leave knowing that person is safe and now has a lower risk of readmitting into hospital because of your visit.

Put out of place...

I had an unfortunate run-in with a pair of nursing staff looking after a specific patient the other day. The patient has severe respiratory compromise associated with consolidation and had low levels of saturation- of which physiotherapy was indicated. Initially, I tried to discuss with the patients nurses when the most appropriate time would be for me to come and assess and treat their patient. This took several attempts due to the fact that the nurse continually ignored my questions and walked away from me several times. After persevering with a nice smile and patience, eventually I was given the ‘ok’ to continue. Between my assessment and treatment, where I had to consult with the supervisor as to my treatment plan etc. the nursing staff had turned the patient from the position I wanted to treat, onto their other side (draining the clear lung and with the clogged up lung on the bottom). Given the patient had been turned and secretions potentially mobilised I had to reassess again and finally treat. After the supervisor and I were happy with the results from treatment, we left the patient. Whilst writing up their notes I was abruptly interrupted by one of the nurses who walked up to me and said ‘You’ve broken the patient’ and just as abruptly walked off. I had a giggle to what happened, and went over to see the patient to make sure things were ok. Consequently the nurse was consecutively suctioning the patient 3-4 times in a row, without any sputum being brought up and without preoxygenating the patient and worried that he was dropping to 85%. Once they’d stabilised I continued writing the notes and overheard the nurse telling the other nurse what had happened, and not so obviously pointing out that it was after physio… I then again got another interruption from the second nurse talking loudly to me to “come listen to what you’ve done”. Going into the patients room and having these two nurses staring me down, I continued to listen to the patients chest (of whom they’d since moved him onto his back now- ie. Remobilised his chest which I nicely explained to them). Anyway his chest sounded fairly clear, which the nurse double-checked with his stethoscope and consequently huffed about the wheeze having disappeared.
After this incident I discussed it with the supervisor and we decided it was just something that should be laughed off, and that the patient had desaturated distinctly 5-10 mins after our treatment and that occasionally blame is passed onto students by some staff members more than others. Since this incident, I don’t feel like I’ve needed to change how to deal with the situation but am reassured that it is important to tell supervisors these things, even if you may consider then banal, so as to ensure they are aware as to any discrimination that may occur during your placement.

Mute patients

Currently being on placement where the majority of your patients are intubated and unable to communicate with you or the outside world, alerts me to the tendency to look at their “numbers” (aka ABGs, UO, ventilation settings) and easily forget patients names and details due to the lack of interaction you have with them. It was a realisation that I had when my supervisor, another student and I were talking over the patient about clinical based questions that I remember that the patient beneath could actually understand/comprehend everything we were saying. With this is mind, I recognised that it was important to still be considerate to the patient in terms of not only introducing yourself, but to still explain what you were going to do with them and the rationale behind it. Despite the fact that they won’t respond or reply to you (they may slightly during treatment), we are unaware as to what mental state they are in. A positive thing that has come out of this placement is the interaction between allied health members. Before and after treating the patient there is the enjoyable task of close liaison opportunities with the nursing staff which you don’t get on other placements. Since noticing, I have made it a focal part of treatment to talk and explain throughout the treatment about what’s happening and continue to thank them at the end of the session which I would if the patient were responsive.

character clashes

Whilst on my rural prac at a fairly large hospital, I developed a character clash with one of the physios in the department who happened to be fairly senior. I am sure everyone has found out that rural pracs are very hectic, and you are thrown in there and just have to get on with it straight away. My orientation to the hospital was good, but obviously you cant get through every small detail of the wards and the physio department in a few hours, and most supervisors and physios are aware of this and expect you to forget things and ask a hundred questions. I was responsible for being in the hydro pool twice a week, and that was all I was told. One of the days of the week, I was in the pool with the physiotherapist I clashed with. She was a lot older than all the other physios in the department, and was not the most welcoming person I have ever met. So on my first day of hydro, I was not quite sure of where all the patients paperwork was, or who was responsible for getting all the paperwork out etc. Unfortunately I was about to discover that that was my job, I just had not been told it on orientation. Also, on this day, for some reason the PTA had overbooked the pool. The physio then went on to give me a lecture on my responsibilities and to basically blame me for the mess. I tried to explain that I really had no idea that that was my job, but she would not hear of it. It was very embarrassing because all the patients were already in the pool. Anyway eventually we got on with the class and I was moving around the pool amongst the patients, and stopped for a second to stretch one of my hamstrings. At that moment she turned around and said that the pool time was for the patients to exercise, not me. I felt yet again so embarrassed and felt that she was now just targeting me for no reason. I felt that she thought I was incompetent, even though I had had good feedback from all the other physios, and I felt she was only seeing bad in me and not anything good that I did.

After the session I was very upset and spoke to my supervisor who was a fairly new grad. She told me that this physio was generally rude to everyone, and that I shouldn’t take it personally. She said that it didn’t really matter in the end what this physio thought of me because she wasn’t assessing me, but I still felt like I wanted her approval. In the end I realised that it wasn’t a personal thing, after I observed her being rude to a number of people that day. But I realised that as a student, it is probably better to just find out as much as you can from your supervisor about what your responsibilities are if you are required to take classes or hydro, so that you are always well prepared. In future I will make a point of finding these things out and clarifying what I am meant to do, so that if I am accused of not doing something I can support myself and say that I had asked but was told that I was responsible for the said job.

difficult patients

Whilst on my orthopaedic placement, I encountered a difficult situation with an elderly man who was about to be discharged after a total hip replacement. Prior to discharge patients are required to safely ascend and descend a flight of stairs in the physio gym on the ward. The patient in question had been a bit difficult from the start, not really paying much attention whenever I went over the precautions and positions to avoid after a hip replacement. I would often come into the room and he would be lying in bed with his legs crossed or lying on his side, and he did not quite seem to grasp why these positions should be avoided. Teaching him how to partial weight bear was a nightmare, and I had to ask my supervisor to help me out a few times to just reinforce to him that these precautions really were important and it wasn’t just that I was a student who was being overly cautious.

The situation occurred while I was taking him through the stairs. It was his second day of trialling the stairs, and I had gone over the order of “good leg first, then the bad leg and then the crutches” for going up the stairs, and “crutches first, then the bad leg and then the good leg” for going down. He was able to repeat this with each step, so after the second trial I stopped repeating the order out loud. The man then decided to try put his good leg down first on the way down the stairs first, meaning that his bad leg was supporting him, and I immediately stopped him and tried to get him to stand up again. He was in a lot of pain understandably, but then he got angry with me because he thought I should have just let him go down as he was. My supervisor was present and came over to help. I explained to him that if he had carried on any further his bad leg would not have been able to take the weight that it was about to take, and that he probably would have fallen. My supervisor agreed and supported me, which made me feel so much better.
He was still quite angry though, and that made me really mad because he had already been so non-compliant and disinterested in listening to instructions, and I had just been waiting for something like this to happen but was kind of mad that he had the audacity to blame me. Anyway I kept my thoughts to myself and he was ok in the end.

I spoke about it with my supervisor afterwards and she was very supportive and said she would have done the same thing. That did make me feel a lot better as I was worried that my decision had been the wrong one. But what I learnt from the whole thing is that even if you think patients understand instructions and you feel that you have been repeating yourself all day, when it comes to safety it is better to just keep repeating the instructions, rather give too much than too little. So in future that is what I will do, especially with non-compliant patients. I also think that you need to tell people that failure to follow the precautions and safety instructions will lead to damage to themselves, and make it very clear from the beginning. And it also might be useful having two people around for patients like this.