From strength to strength – My transformational journey 2016

 “Without continual growth and progress, such words as improvement, achievement and success have no meaning.” – Ben Jamin Franklin.

At the start of my 4th year, I knew that some of my personal and professional challenges would be to endure daily trauma and the hospital environment with which I am uncomfortable. A further challenge was going to be to manage my daily patient workload preparation as well as varsity work. I had concerns over limited financial resources and to get to my different placements traveling long distances. I also doubted my ability to successfully treat patients and applying my practical skills and theory in real life situations where treatment and the wrong decisions could impact a real life patient.

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I was fortunate that over the course of the year I could address these challenges. I improved my communication skills and my eagerness to learn, improved my knowledge base and I could see how my treatments and empathy contributed to the wellbeing of my patients. According to Chipchase et.al. ( 2012), these are all characteristics of a well prepared and professional student.

Clinical reasoning refers to the thinking and decision-making processes that are used in clinical practice (Edwards, Jones, Carr, Braunack-Mayer, & Jensen, 2004). I built up my confidence by trusting my training, relying on clinical reasoning and research to back me up. I changing my mind set from dreading hospitals to positively embracing the learning experience and the growth that comes with conquering difficult circumstances. Every patient and every situation is different and brings with it its own challenges. It was so rewarding to see, how having empathy with a patient and applying clinical reasoning contributed to my treatment plans being more effective.

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The ICU is a daunting place, Not only was I faced with the personal challenge of being in an ICU for the first time; I also had to face the responsibility of treating critically ill patients effectively. When treating ICU patients there is no room for error.

In this “life and death” environment, I realised the value of a well-functioning Multi-Disciplinary team (MDT). Clinicians and other members of the MDT play a critical role in guiding students clinically but also demonstrating the medical ethical principles of respect for autonomy, non-maleficence, beneficence and justice (Peel, 2005).

In the ICU I was faced with life and death decisions on a daily basis. The one day the patient was there and coming back after a weekend the patient was declared brain dead or they just didn’t make it. This was traumatic for me and I questioned my faith in a good God who can allow so much trauma. As I worked through my feelings, I realised that I have a privileged & critical role to play in each patient’s life by bringing hope and treatment into sometimes hopeless situations. This brought meaning and purpose to my days.

A multidisciplinary team (MDT) is composed of members from different healthcare professions with specialised skills and expertise. The members collaborate together to make treatment recommendations that facilitate quality patient care. Multidisciplinary teams aim to address treatment that is focused on both the physical and psychological needs of the patient (Department of Health – Multidisciplinary Teams, n.d.).

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During my ICU block I experienced how a MDT failed as an unknown patient passed away before his family could see him. His family was in the ICU looking for him but because the night staff did not hand over properly the day staff was not aware that he was unknown. As the day progressed the family looked for this patient in my ward as well and I was distraught at the fact that positive identification and goodbyes slipped by as a result of MDT lack of communication.

I experienced doctors who openly spoke about patients as if they were assets and not a human being fighting for their life. This was against the principle of respect for a patient and unprofessional as such discussions need to happen behind closed doors. I struggled to digest that professionals, who have a title to their name, assume they have all the power and that a patient’s life depend on them alone. Ethically this was wrong as the patient was still alive and deserved a fighting chance. In my time at the ICU, one patient was given a fighting chance and it was so rewarding seeing him recover in the wards and going from strength to strength.

Literature is in support of the physicians. It is of utmost importance that a physician recognizes when they are dealing with a dying patient. Besides planning for relief of symptoms and treatment, an ICU physician must understand decision making and advanced orders, be effective in the interaction with families, understand the influence of religion and spirituality, acknowledge diversity, be facile with palliation and transition to comfort care, communicate well with the primary care team and enlighten medical students and residents regarding end-of-life issues (Papadimos, Tripathi, Rosenberg, Maldonado, & Kothari, 2011).

As students it was emphasized how important it is to work in a MDT with all the other professions and during my 4th year I learnt the importance of working together as a MDT and the benefits it brings to the patient. In the health profession everyone has a different personality, views on ethics and professional conduct.

I experienced Tygerberg Hospital as a place where each one is for himself and the professional only does what is required of them. This attitude resulted in a polytrauma patient of mine going one week without surgery to her multiple fractures as they were always waiting on someone to deliver. This is against the patient’s right to treatment as well as the principle to act in a patient’s best interest. Overall the patient was being disadvantaged. In contrast, at Red Cross Hospital, each member of the team will go the extra mile for their patient and at WCRC the MDT’s are very effective in delivering high quality healthcare ensuring justice and beneficence for all patients.

Participants in a study by Ernstzen (2013), agreed that the attributes of the clinical educator that are conducive to learning are approachability, recognising student abilities, and good communication skills. Although I had a very good clinician in my ICU block, some clinicians address you as a student in a way that makes you feel inferior.

On one specific day I was doing chest physiotherapy on a patient and a clinician barged into my session, criticised and questioned everything I did and walked out. I knew the right thing to do was for the clinician to talk through the situation with me and teach me but instead she left me feeling incompetent and embarrassed. At this point I wanted to have a discussion with the clinician, but I thought I would not gain anything as she would always be right. In my view she handled the situation incorrectly, unprofessionally and did not train me properly to be of better value and affect to the patient next time. I reminded myself of who I am and what I stand for as well as what my purpose is – to treat my patients as best I can and put their needs and feelings above mine. Although the clinician was right theoretically, the patient was traumatised and confused and my empathy and caring calmed him and allowed my treatment to be more effective as I treated him more holistically. I learned that through empathy and encouragement you can win a patient’s co-operation.

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I experienced Clinicians mostly as unfriendly and unapproachable due to their positions, but I learned from this experience and was able to deal with Clinicians differently in later blocks. For example, at WCRC, a particular clinician’s reputation as an intimidating and unapproachable clinician preceded her. I decided to take on the challenge and learn from her as a physiotherapist as much as I could. It ended up being a very rewarding and educational experience for me.

During my exam at WCRC I was marked down for not finishing my treatment session as my patient asked to stop due to pain. I respected her wishes and told my examiner my patient’s well-being is more important than my exam. A patient has autonomy and the right to refuse treatment but I also have a responsibility to know when to stop and when to push a patient forward.

As a Physiotherapist it is important to always stay grounded and know that you do not know everything and there are always opportunities to learn, grow and improve. At the Western Cape Sports School I learnt that it is important to go into every clinical situation with an open mind and ready to learn and to consult with other members of a MDT. If not, your patient will come second as your ego and image is more important.

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During my 4th block I experienced challenges with time management as I was expected to see between 9 and 11 patients on some days. As a student we are expected to see 7 patients a day as we are on clinical rotation to learn and gain experience, not take workload off of clinicians. On many occasions during this block I was told I have poor time management as I cannot fully assess, treat and do admin on time. I felt exploited on this block as well as emotionally abused, I speak about this in my blog post ‘Do not be ashamed of your story, it will inspire others’. My clinician was a comserve and I had thought she would be more understanding as she was where I was just a few months ago.

I discovered my clinician would write SOAP notes but she would not treat the patient. This raised red flags for me as it was unethical and unprofessional. According to the HPCSA guidelines on Reporting of impairment or of unprofessional, illegal or unethical conduct (25) I had the right to report the clinician and I brought it to my supervisor’s attention. I speak about more ethical and moral situations in my blog post ‘Being who I am in a world who wants me to be someone else’.

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At TBH I was introduced to ganster paradise where most cases are gansters who have suffered polytrauma. When I started clinicals at GSH treating gansters there I felt unsafe, fearful and struggled to accept the fact that they too deserve fair and equal treatment. Due to my personal and professional development I realised that I am not the judge of their actions and that adhering to the medical ethical principles of justice and beneficence I have a responsibility towards them as a healthcare professional. Therefore at TBH I had more confidence in myself and treated the patients holistically.

Working with children brings its own set of challenges. Treating ill children who are traumatised, in pain and sometimes lonely, forces you to come down to their level. Involving the children’s parents was something I had to get use to as in other clinical rotations adults cooperate and understand. One of the biggest challenges I faced at Red Cross Hospital was when a child refused treatment. Ethically the patient has a right to refuse treatment but in this case the patient is a minor. In situations such as these I encouraged play to achieve my treatment goals and if all else failed I had to get assistance and force it onto the child. Morally this is against what I believe but in the long run the patient will benefit from the treatment. There is something about working with children that change the way you see yourself as well as the purpose of your profession. Compassion was my best friend but I had to prevent myself from being emotionally attached to the cases. Empathy doesn’t mean one is weak, it simply means you’re human with a heart and in my experience it allowed me to treat my patients more effectively.

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Looking at the challenges I faced in the beginning of my 4th year I now feel confident to work in a hospital setting and treat traumatised patients. I conquered the personal difficulty of financial restrictions and rose above all the challenging situations I was faced with including the workload and Fees must fall movement; which despite all the interuptions, I stayed focused to finish strong and not let it affect my patients’ care. This journey has helped shape me into the physiotherapist I want to be.

 

REFERENCES:

Chipchase, L. S., Buttrum, P. J., Dunwoodie, R., Hill, A. E., Mandrusiak, A., & Moran, M. (2012). Characteristics of student preparedness for clinical learning: clinical educator perspectives using the Delphi approach. BMC Medical Education12(1). doi:10.1186/1472-6920-12-112

Department of Health – Multidisciplinary Teams. (n.d.). Retrieved from http://www.health.nt.gov.au/Cancer_Services/CanNET_NT/Multidisciplinary_Teams/index.aspx

Edwards, I., Jones, M., Carr, J., Braunack-Mayer, A., & Jensen, G. M. (2004). Clinical Reasoning Strategies in Physical Therapy. Physical Therapy Journal, 84(4), 312-330.

Ernstzen, D. V. (2013). Roles and attributes of physiotherapy clinical educators: Is there agreement between educators and students? AJHPE, 5(2), 91.

Papadimos, T., Tripathi, R., Rosenberg, A., Maldonado, Y., & Kothari, D. (2011). An overview of end-of-life issues in the intensive care unit. International Journal of Critical Illness and Injury Science, 1(2), 138.

Peel, M. (2005). Human rights and medical ethics. Journal of the Royal Society of Medicine, 98(4), 171–173.

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