Situation: I had been treating a middle aged gentleman who had come onto the ward with an acute exacerbation of COPD for about a week and was not really seeing any improvements in his function. The man was a CO2 retainer, usually had home oxygen (O2) and had severely decreased exercise tolerance, walking a maximum of about 30m with a wheeled zimmer frame (WZF) at home before he had to have a rest because of shortness of breath. Since being in hospital it hadn’t purely been his exercise tolerance that was the problem as he could still walk about 30m, but he was just much more short of breath after doing so. He was also having difficulty clearing his increased amount of secretions. Whilst being in hospital he had also developed gout in his foot, which was very painful and subsequently we abandoned the plan to walk on consecutive days because of this pain. When this pain was being controlled better, we were able to walk 30m with a WZF on 2L of O2/min with a 2 minute break at 15m because of the shortness of breath (Rated at 8/10 on a Borg Scale by the man.) Other interventions in my treatment sessions included deep breathing exercises, active cycle of breathing techniques (ACBT), supported cough, expiratory vibes and breathlessness relieving positions. After this session, I had a particularly long think about what I could differently next time I treated the man and identified that I could try ambulation with a 4 wheeled walker (4WW) as it would have a seat and may help the man with his shortness of breath recovery time if he were to sit down if he did become more short of breath.
Task: My task was to perform my daily respiratory and mobility treatment for the man, with the plan of trialling ambulation with a 4WW and oxygen rather than WZF.
Action: I started my session with subjective questioning about how the man had been since I saw him previously and then took his obs so that that I had up to date figures that I could use as outcome measures. The patient reported his shortness of breath at rest was 6/10 on the Borg scale, his gout pain was negligible, but feet pain secondary to his usual peripheral oedema was 2/10 on a pain scale, his blood pressure was 117/81 and oxygen saturation was 92% on 2L of O2 per minute. Being a CO2 retainer, I was to expect that his sats would be around 88-92%, so this was an acceptable level to be walking with him, so that was definitely the plan for my first intervention of the session. He told me he was very keen to try the 4WW as he thought it would be a great aid for him to use upon discharge if it was beneficial for him. I switched his oxygen source over to a portable bottle and turned it onto 2L/min and I kept the pulse oximeter on, so that I could monitor his sats as we walked as he did have a history of de-satting. I would look after the portable oxygen and pulse oximeter and just follow the patient as he walked. I knew he was independent with his walking, so we were ready to go.
After walking about 10 metres outside his room the man quickly became short of breath and his sats began to fall quite rapidly. 5 metres further and the man complained of 9/10 breathlessness and his sats were 88%, the oximeter showed a good pulse so I was confident I was getting an accurate reading but I made the man have a sit down on the 4WW’s seat because of his symptoms. In the breathlessness relieving position of forward lean sitting and performing some deep breathing the man was still not recovering and his sats dropped to 86%. It was then that my supervisor walked past after seeing a patient of his own and checked to see if everything was alright with me and my patient. When I told him that the man was in a bit of distress after the short walk the first thing he did was check the portable oxygen bottle. To my surprise there was no oxygen coming out of the bottle and after being questioned as to whether I had turned it on, which my patient and I were both certain that I had, and after altering the flow dials to no avail, we came to the conclusion that the bottle had run out of oxygen, so I quickly got a new bottle and swapped it over. After making the switch the man quickly recovered to a SOB of 6/10 and sats of 91% and was happy to continue on with the walk, which we did.
Result: The result was that he was able to walk a total of 30m in returning to his room without needing to take a break. On completion his sats were 89% and SOB 7/10, so he had deteriorated a little, but not significantly like the previous day or initial walk. After 2 mins of forward lean sitting and deep breathing the man had returned to his baseline sats of 92% and 6/10 shortness of breath, which was a much more rapid recovery than previous efforts. I felt that the increased distance walked, smaller sats and SOB deterioration and quicker recovery were a significant enough result to warrant switching the patient to ambulation with a 4WW as opposed to a WZF. The man was also very pleased with his efforts.
Evaluation: I feel that my rationale and thinking about this patient’s intervention were pretty good, as demonstrated by the eventual improved ambulation performance with the 4WW. However, I believe my initial execution of the intervention showed a lot of inexperience as I did not execute it very well, which showed with the man’s first attempt to walk with the 4WW. After a discussion with my supervisor he said that despite the fact it wasn’t my fault that the oxygen bottle had run out oxygen, it’s still my job to be aware of the possibility and check and prevent it from occurring with a patient. As I said, it was just an inexperience factor, but I did not check to see how much oxygen was still in the bottle when I turned it on, I was only concerned that it was initially producing 2L per minute, something that I now know to look out for in the future. Despite this, I feel most of this particular intervention was done well on my behalf, mainly in reference to the outcome measures and other safety precautions that I had in place. Taking the pulse oximeter with us and having a Borg scale shortness of breath rating was a good decision, because although the man had de-satted more on previous occasions than the 86-88%, it was the rapid fall combined with the symptomatic shortness of breath response that alerted me to the need for the man to stop and recover. Leaving the 4WW in the patient’s room was also a good idea because it means he can become more familiar with it prior to his discharge, which will help facilitate a safe return to home for the man.
Strategies: The obvious strategy that I will take out of this situation is the need to always check the working order of portable oxygen bottles before walking a patient with them. I now know to always check the gauge to make sure the bottle is not nearly empty. This does not just have to apply to portable oxygen though, it’s alerted me to the fact that all devices or equipment should be regularly checked to ensure they are in correct working order, so as not to put the wellbeing of our patients under scrutiny. One of the aspects I felt I did well in this scenario was evaluate the situation to see what else I could do to further improve the outcome for my patient. It certainly was not the first time I have done this and I feel that I am pretty good at reflecting and evaluating after seeing all of my patients, however it was just a good example of why I should continue to do this, as the result of changing the man’s ambulation aid to a 4WW produced significant performance improvement compared to previous sessions. The benefit of a 4WW’s seat for people who get short of breath on exertion is also something I will remember, because it means they have an effective walking aid plus the bonus of a mobile place to sit to recover when they do become short of breath. One final thing which my university tutor helped me to identify was the need to make treatment session plans and then stick to them. In this case, I decided I wanted the man to trial walking with a 4WW and despite the initial events with the oxygen bottle I still carried through with this plan so that I could assess the benefit of this particular ambulation aid for the man. By completing what I had planned to achieve, I was able to identify that the man did indeed perform better with the 4WW compared to the WZF and thus was able to leave it in his room for him to continue using in the future.
Sunday, May 30, 2010
Sunday, May 16, 2010
Entry 1: Professional Behaviour
Situation: On my second day at Fremantle Hospital, my clinical tutor was spending time with both Monique and myself for the entire day. For the first part of the morning we discussed expectations and had a bit of a generalised tutorial about what to expect and how to get the most out of a cardiorespiratory placement. After this we went on to the ward to prepare for our first patient of the placement. We were shown how to analyse patient notes for relevant information to get an idea as to what the patient will look like and their capabilities before we initially see them. Our tutor also showed us how to review all the relevant investigations that have been performed on the patient, such as chest x-rays and bloods, all so that we could see the correct process that should be followed before seeing a patient. Once this preparation process was complete, our tutor went to the patient just to check she was happy to be seen by students and when we got the okay we took a lunch break knowing we were ready to see the patient immediately after lunch. During our lunch break, Monique and I decided that she would perform the subjective assessment, then I would be objectively assessing the patient.
When we met up with our tutor after lunch we went straight in to see the patient. She was an elderly woman who had pneumonia, with a productive cough and very decreased exercise tolerance. She was also being investigated for another infection, subsequently she was in a single room and we all had to wear precautionary gown and gloves before entering the room. Once inside the room, our tutor introduced us and then handed control over to Monique, who was ready to start her subjective questioning. Monique was conducting an initial assessment as she had been instructed to do by our tutor and was about 6 questions into it when we began to see that this was not going to be the easiest patient. The patient began questioning Monique and what she was doing and when this was initially happening I thought it was a bit of a joke, but when she continued to do it I realised that the patient actually meant what she was saying. Right now I’d like to make it be known that I thought Monique was doing a great job with her assessment and there was absolutely nothing wrong with her questioning, she was being clear and asking appropriate things and I wouldn’t have faulted her at all. She continued with her questions, but the patient continued with her ‘treatment’ on Monique as well. The patient kept telling her that she was doing things wrong and then started mimicking her and actually verbally insulting her, then told her to go away. After this our tutor stepped in to relieve a slightly upset Monique by continuing with a partly modified subjective assessment. Then she finished and handed control over to me.
Task: My task was to perform the objective assessment on the patient. This was to include an initial respiratory assessment, which would consist of a cough, chest expansion and auscultation assessment. In addition I was to perform a mobility assessment of things such as bed mobility, transfers and ambulation.
Action: When I was starting I was just praying that the patient would be a bit more friendly and cooperative with me than she had been with Monique. I was able to get her to cough so that I could assess it without much difficulty. Then I wanted to auscultate to listen to her breath sounds, but first asked for consent to do this. The woman got very annoyed that I had asked for her permission to do this as she felt everything was already taking too long and thought I should have just done it anyway. I explained that I would not do the auscultation if she did not approve and then she began explaining her extensive thoughts about how stupid it was that I had to get her consent before performing the assessment, before finally allowing me to do it. During this assessment, I unfortunately forgot that you can’t hear yourself as loudly when you speak with stethoscope ear pieces in and proceeded to speak at an increased volume right next to the patient’s ear as I was listening to her chest. She was very quick to let me know that she was not deaf and there was “no need for me to shout,” which was quite embarrassing. When I finished auscultating I explained that the final thing I had to do was assess her current level of mobility. This also turned out to be a very long and difficult process, but I was eventually able to get her to walk approx 2 metres with a wheeled zimmer frame before she needed to sit down and rest on a chair. After a few minutes she felt able to walk back to her original bed side chair and this is what we did. Once back in the chair, the woman immediately cleared some sputum into her tissue, but refused to let myself or anyone else look at what she had cleared. We were then unable to persuade the patient to perform any further mobility assessments or even clearance exercises such as the ACBT despite there clearly being a need for it. I finished by auscultating the lungs again and we finished and left the room.
Result: The result was that my respiratory assessment did not include a chest expansion assessment and the mobility assessment only comprised of sit to stands and ambulation. Despite it not being one of my individual set tasks, Monique and I still would have liked to perform some form of treatment, which did not eventuate either, meaning the woman was left with uncleared secretions remaining in her airways when we finished with her. This certainly was not a desirable outcome and in addition to this, both Monique and I left the patient’s room feeling a bit lower and more dejected than when we had entered over 45 minutes earlier.
Evaluation: On evaluation I feel I let the way the patient treated Monique initially affect my part of the assessment a lot more than it should have. I feel that I forgot to feel the patient’s chest expansion because I was so concerned with what she was thinking about me and what she was going to say to me. Despite this being the first patient I had assessed on this placement, I feel it was a poor effort to forget one of only three things from my assessment because of nerves and because of this action particularly I was disappointed with myself. In regards to the mobility assessment, there’s not much more you can do when a patient is refusing to cooperate with you like this patient was. I couldn’t assess her mobility if she wasn’t willing to move around for me, perhaps the only thing I could have done was persuade her further, but apart from this, my attempt at a mobility assessment was about as good as it could have been under the circumstances. When we finished, Monique and I had a very long discussion with our tutor about how things had gone with the patient. She told both of us that she felt we handled the situation pretty well and again that under the circumstances, being quite a difficult patient, we both performed well. She also gave us a few tips and strategies to use if we find ourselves in a similar situation again.
Strategies: Our tutor told us that when we have difficult patients one of the best things you can do is to give them what they want. She used the example of when Monique was asking her initial subjective questions and said that the patient had most likely been asked those questions (eg. Are you a smoker? Do you have a cough?) many times before and that she would have been wanting more questions relating to her current state. The tutor said the better questions to ask would have been about how she was coping that day, if there was any pain that day and if she had been coughing a lot recently? This, rather than the more initial subjective history questions that were asked by Monique as she was performing her set task. Another thing the tutor said to do was have checklists made up that we could either think of or refer to when we are treating our patients. By having a checklist or set routine that you follow, then you are much less likely to miss something important, such as part of your assessment process. One of the things that I noticed the tutor do when she was speaking to the patient was identify that she really wanted to go back to her hostel as soon as possible. She then said the quicker she lets us perform our assessments the quicker we could tell the rest of the team when we felt she was ready to be discharged. This immediately made the patient more cooperative than she initially was with the assessment process. I believe this was an appropriate action to take with this particular patient and I feel that depending on the person sitting in front of me, I also may decide that a method like this could be employed to help with patient persuasion into cooperation with you and your efforts. I also learnt that you can’t let yourself get flustered by difficult patients because it impairs your normal thought processes and interferes with your work. This one however, is probably easier said than done, but something that I intend to try my very best to adhere to. Finally, I learnt that you must speak softly to a patient while you have stethoscope ear pieces in.
When we met up with our tutor after lunch we went straight in to see the patient. She was an elderly woman who had pneumonia, with a productive cough and very decreased exercise tolerance. She was also being investigated for another infection, subsequently she was in a single room and we all had to wear precautionary gown and gloves before entering the room. Once inside the room, our tutor introduced us and then handed control over to Monique, who was ready to start her subjective questioning. Monique was conducting an initial assessment as she had been instructed to do by our tutor and was about 6 questions into it when we began to see that this was not going to be the easiest patient. The patient began questioning Monique and what she was doing and when this was initially happening I thought it was a bit of a joke, but when she continued to do it I realised that the patient actually meant what she was saying. Right now I’d like to make it be known that I thought Monique was doing a great job with her assessment and there was absolutely nothing wrong with her questioning, she was being clear and asking appropriate things and I wouldn’t have faulted her at all. She continued with her questions, but the patient continued with her ‘treatment’ on Monique as well. The patient kept telling her that she was doing things wrong and then started mimicking her and actually verbally insulting her, then told her to go away. After this our tutor stepped in to relieve a slightly upset Monique by continuing with a partly modified subjective assessment. Then she finished and handed control over to me.
Task: My task was to perform the objective assessment on the patient. This was to include an initial respiratory assessment, which would consist of a cough, chest expansion and auscultation assessment. In addition I was to perform a mobility assessment of things such as bed mobility, transfers and ambulation.
Action: When I was starting I was just praying that the patient would be a bit more friendly and cooperative with me than she had been with Monique. I was able to get her to cough so that I could assess it without much difficulty. Then I wanted to auscultate to listen to her breath sounds, but first asked for consent to do this. The woman got very annoyed that I had asked for her permission to do this as she felt everything was already taking too long and thought I should have just done it anyway. I explained that I would not do the auscultation if she did not approve and then she began explaining her extensive thoughts about how stupid it was that I had to get her consent before performing the assessment, before finally allowing me to do it. During this assessment, I unfortunately forgot that you can’t hear yourself as loudly when you speak with stethoscope ear pieces in and proceeded to speak at an increased volume right next to the patient’s ear as I was listening to her chest. She was very quick to let me know that she was not deaf and there was “no need for me to shout,” which was quite embarrassing. When I finished auscultating I explained that the final thing I had to do was assess her current level of mobility. This also turned out to be a very long and difficult process, but I was eventually able to get her to walk approx 2 metres with a wheeled zimmer frame before she needed to sit down and rest on a chair. After a few minutes she felt able to walk back to her original bed side chair and this is what we did. Once back in the chair, the woman immediately cleared some sputum into her tissue, but refused to let myself or anyone else look at what she had cleared. We were then unable to persuade the patient to perform any further mobility assessments or even clearance exercises such as the ACBT despite there clearly being a need for it. I finished by auscultating the lungs again and we finished and left the room.
Result: The result was that my respiratory assessment did not include a chest expansion assessment and the mobility assessment only comprised of sit to stands and ambulation. Despite it not being one of my individual set tasks, Monique and I still would have liked to perform some form of treatment, which did not eventuate either, meaning the woman was left with uncleared secretions remaining in her airways when we finished with her. This certainly was not a desirable outcome and in addition to this, both Monique and I left the patient’s room feeling a bit lower and more dejected than when we had entered over 45 minutes earlier.
Evaluation: On evaluation I feel I let the way the patient treated Monique initially affect my part of the assessment a lot more than it should have. I feel that I forgot to feel the patient’s chest expansion because I was so concerned with what she was thinking about me and what she was going to say to me. Despite this being the first patient I had assessed on this placement, I feel it was a poor effort to forget one of only three things from my assessment because of nerves and because of this action particularly I was disappointed with myself. In regards to the mobility assessment, there’s not much more you can do when a patient is refusing to cooperate with you like this patient was. I couldn’t assess her mobility if she wasn’t willing to move around for me, perhaps the only thing I could have done was persuade her further, but apart from this, my attempt at a mobility assessment was about as good as it could have been under the circumstances. When we finished, Monique and I had a very long discussion with our tutor about how things had gone with the patient. She told both of us that she felt we handled the situation pretty well and again that under the circumstances, being quite a difficult patient, we both performed well. She also gave us a few tips and strategies to use if we find ourselves in a similar situation again.
Strategies: Our tutor told us that when we have difficult patients one of the best things you can do is to give them what they want. She used the example of when Monique was asking her initial subjective questions and said that the patient had most likely been asked those questions (eg. Are you a smoker? Do you have a cough?) many times before and that she would have been wanting more questions relating to her current state. The tutor said the better questions to ask would have been about how she was coping that day, if there was any pain that day and if she had been coughing a lot recently? This, rather than the more initial subjective history questions that were asked by Monique as she was performing her set task. Another thing the tutor said to do was have checklists made up that we could either think of or refer to when we are treating our patients. By having a checklist or set routine that you follow, then you are much less likely to miss something important, such as part of your assessment process. One of the things that I noticed the tutor do when she was speaking to the patient was identify that she really wanted to go back to her hostel as soon as possible. She then said the quicker she lets us perform our assessments the quicker we could tell the rest of the team when we felt she was ready to be discharged. This immediately made the patient more cooperative than she initially was with the assessment process. I believe this was an appropriate action to take with this particular patient and I feel that depending on the person sitting in front of me, I also may decide that a method like this could be employed to help with patient persuasion into cooperation with you and your efforts. I also learnt that you can’t let yourself get flustered by difficult patients because it impairs your normal thought processes and interferes with your work. This one however, is probably easier said than done, but something that I intend to try my very best to adhere to. Finally, I learnt that you must speak softly to a patient while you have stethoscope ear pieces in.
Sunday, May 9, 2010
Initial Entry
My third clinical placement for the year is cardiorespiratory at Fremantle Hospital and I am looking forward to it. I am half way through my four placements for the year and the finishing line is getting closer and closer, which is very exciting. I feel my preparation for this placement has been much better than the previous two, which I am hoping will serve me well through the five weeks. After the two previous efforts I feel that I was able to prepare more effectively and thoroughly this time round and made use of past student, university and facility revision recommendations to aid in my study endeavours. Having said this though, I am still very nervous about what the next five weeks will hold, because I think this placement will be very different again to what I have encountered previously.
I am not entirely sure about the nature of this placement, because the orientation outline provided by the facility has suggested six different areas that I could possibly be involved with while on my cardiorespiratory placement. These are General Medical, General Surgical, Cardiothoracics, Intensive Care Unit, Ambulatory Care and Haematology and Oncology, certainly a wide variety of possibilities. No matter which area I am working in, I do expect it to be fast paced and at times hectic with the number of duties I will be expected to fulfil. In terms of placement structure, I have read from the orientation outline that Fremantle Hospital placements use a “peer-coaching model,” which I am assuming involves working pretty closely with another or other students that are also on placement. I am expecting that initially I will be working alongside another student and a supervisor, but as the placement progresses the degree of supervision will decrease as we become more familiar with the facility, then to the point where I will be operating without a partner. I expect that as time goes by my case load will increase as I become more proficient with my duties. I feel that there will also be greater expectations on me to be able to perform these duties effectively and efficiently and that despite being a student I should be a contributing member of the multidisciplinary team. I believe my role as a student will be to learn and progress my skills, knowledge and capabilities as much as possible, but also to be an effective team member and contribute as much as possible as I previously mentioned.
I mentioned at the beginning of my previous placement that I was concerned about my time management skills and I would have to admit I still feel the same way now. At Osborne Park Hospital I was given my daily timetable which had my patients sorted into allocated time slots and I just stuck to this as best as possible. Despite the convenience of this system, it didn’t really challenge my time management skills, which is why I am still a bit concerned about it heading to Fremantle Hospital. Particularly the patient prioritisation aspect of time management, which Shane has told us can be very difficult in this area, especially with a large case load, is something that I would like to discuss with my supervisor pretty early on in the placement, so that I am able to cope with the demands placed on me and be as efficient as possible.
Another concern of mine is my ability to perform some techniques and treatments that we have learnt about and practiced at uni but I have never performed on a patient. I am nervous about things such as percussion and vibrations, suctioning, mechanical ventilators and just the management and awareness of attachments like ICCs and different lines. I hope that with these treatments and other aspects that I will get some guidance from my supervisor when I am initially performing or administering them, but if not I will just have to rely on my previous teachings and readings to get me through. I am hoping that after five weeks of these sorts of treatments I will have the techniques all sorted out, but the practical performance on a patient is something that is a bit of a concern to me currently.
Finally, I am very much hoping that I quickly develop a tolerance to the sputum, vomit and other bodily fluids/contents that I am sure I’ll be seeing quite a bit of on this placement. I’m fine with blood and have seen surgeries in the past and been fine, but I realised on my last placement that I’m not the best with some of the other secretions that we as physiotherapists are exposed to. It sounds pretty silly, but it is something I’m genuinely concerned about at this point in time. I’m going to have to train myself to toughen up and deal with it pretty quick, otherwise it’s going to be a long five weeks!
Despite these concerns, I am looking forward to getting this placement underway. From the information I have read from the facility and feedback from others this does seem like a good environment to be in as a student. I realise there is added expectations surrounding me as this is one of my final placements, but I’m sure I will be able to handle it and will perform well. I definitely intend to get as much as I possibly can out of this placement and hope I can enjoy it too.
Ready, Set, Go!
I am not entirely sure about the nature of this placement, because the orientation outline provided by the facility has suggested six different areas that I could possibly be involved with while on my cardiorespiratory placement. These are General Medical, General Surgical, Cardiothoracics, Intensive Care Unit, Ambulatory Care and Haematology and Oncology, certainly a wide variety of possibilities. No matter which area I am working in, I do expect it to be fast paced and at times hectic with the number of duties I will be expected to fulfil. In terms of placement structure, I have read from the orientation outline that Fremantle Hospital placements use a “peer-coaching model,” which I am assuming involves working pretty closely with another or other students that are also on placement. I am expecting that initially I will be working alongside another student and a supervisor, but as the placement progresses the degree of supervision will decrease as we become more familiar with the facility, then to the point where I will be operating without a partner. I expect that as time goes by my case load will increase as I become more proficient with my duties. I feel that there will also be greater expectations on me to be able to perform these duties effectively and efficiently and that despite being a student I should be a contributing member of the multidisciplinary team. I believe my role as a student will be to learn and progress my skills, knowledge and capabilities as much as possible, but also to be an effective team member and contribute as much as possible as I previously mentioned.
I mentioned at the beginning of my previous placement that I was concerned about my time management skills and I would have to admit I still feel the same way now. At Osborne Park Hospital I was given my daily timetable which had my patients sorted into allocated time slots and I just stuck to this as best as possible. Despite the convenience of this system, it didn’t really challenge my time management skills, which is why I am still a bit concerned about it heading to Fremantle Hospital. Particularly the patient prioritisation aspect of time management, which Shane has told us can be very difficult in this area, especially with a large case load, is something that I would like to discuss with my supervisor pretty early on in the placement, so that I am able to cope with the demands placed on me and be as efficient as possible.
Another concern of mine is my ability to perform some techniques and treatments that we have learnt about and practiced at uni but I have never performed on a patient. I am nervous about things such as percussion and vibrations, suctioning, mechanical ventilators and just the management and awareness of attachments like ICCs and different lines. I hope that with these treatments and other aspects that I will get some guidance from my supervisor when I am initially performing or administering them, but if not I will just have to rely on my previous teachings and readings to get me through. I am hoping that after five weeks of these sorts of treatments I will have the techniques all sorted out, but the practical performance on a patient is something that is a bit of a concern to me currently.
Finally, I am very much hoping that I quickly develop a tolerance to the sputum, vomit and other bodily fluids/contents that I am sure I’ll be seeing quite a bit of on this placement. I’m fine with blood and have seen surgeries in the past and been fine, but I realised on my last placement that I’m not the best with some of the other secretions that we as physiotherapists are exposed to. It sounds pretty silly, but it is something I’m genuinely concerned about at this point in time. I’m going to have to train myself to toughen up and deal with it pretty quick, otherwise it’s going to be a long five weeks!
Despite these concerns, I am looking forward to getting this placement underway. From the information I have read from the facility and feedback from others this does seem like a good environment to be in as a student. I realise there is added expectations surrounding me as this is one of my final placements, but I’m sure I will be able to handle it and will perform well. I definitely intend to get as much as I possibly can out of this placement and hope I can enjoy it too.
Ready, Set, Go!
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