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.