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Community spirit: a student nurse's encounter

Moyra Swan
BSc(Hons) BA
Postgraduate Student Nurse

As a student on a postgraduate nursing diploma course I have an unforeseen bonus: my placements are longer than average, lasting around three months, thus providing a welcome opportunity for me to get really involved and to experience the work of a variety of members of the primary care team.
Before I started my placement I had little idea of what to expect, having spent all my other placements on hospital wards. Some students had been dismissive: "You spend most of your time on your knees doing bandages - it's all leg ulcers." But this is not at all how I interpreted the experience.

More than just ulcers
My mentor was a district nurse  - and yes, that did indeed mean leg ulcers, but this blanket term in no way did justice to the wide variety of wounds that we assessed and treated each day. I soon discovered that leg ulcers are far from being a homogenous entity, and I learnt the important differences between venous and arterial; the process of healing postsurgery; pressure sores; the organisms that can infect wounds; the complex choice of dressings and treatments available; and the skill of bandaging. I perceived wound management as a constantly evolving and dynamic specialism.
Once I'd got the hang of it I found dressing and bandaging very satisfying. An activity that allowed me to hone my multi-tasking skills by listening and responding to the patient's news and views while assessing their wounds, choosing the relevant dressings and applying them correctly.
It was also an holistic activity; I learnt much about the patients' general state of physical and mental health while "on my knees". After some weeks I was allocated my own patient group and relished the responsibility and the trust that was placed in me.

Delayed diagnosis
During my placement I encountered an uncommon autoimmune ulcerative condition, pyoderma gangrenosum, linked to the patient's pre-existing rheumatoid arthritis.(1) I visited this patient regularly, once with the tissue viability specialist nurse, whom my mentor had consulted as the leg ulcers were not healing as expected. Neither the GP nor the vascular consultant had diagnosed this condition, but once the tissue viability nurse had done so the patient was referred (through the GP) to a dermatologist, whose opinion concurred with that of the nurse, and treatment with the immunosuppressant CellCept and an increased dose of steroids was commenced.(2) It seemed to me that the patient would have benefited sooner had the recent government initiative on expanding the prescribing role of nurses already been in place.(3) Extended nurse prescribing is surely an overdue improvement in primary care.

Changing attitudes
As I browsed the GPs' journals in the surgery staff room during coffee breaks I noted that there was much resistance expressed to the changing role of nurses,(4,5) and I fear it may well be some time before attitudes change and patients get the relevant specialist care from whoever is best equipped to provide it.
The 2005 government publication Supporting People with Long Term Conditions states that the "strategic aim" is to increase support for patients in the community, thus taking the burden off hospital beds and increasing patients' opportunities for treatment in their own homes.(6)
If these aims are achieved then primary care, including extended nurse prescribing, will be an exciting area in which to work, with increased opportunities for nurses to enhance the quality of life of patients.
During my placement my mentor supported me in my choice to spend time with other specialists, such as the practice nurse, Macmillan nurse, health visitor and midwife.
The knowledge and insight I gained was invaluable, and I can only touch on it here. I took part in clinics and visits concerned with cardiac rehabilitation, child immunisation, maternity, children at risk, diabetes, smoking cessation, asthma and wellbeing. I saw how varied people's reactions can be to discussions concerning their lifestyle. I also learnt the practical skills of venepuncture, ECG recording, immunisation and flu jab administration. How accommodating those patients were!
My placement was stimulating and thought-provoking, and the 12 weeks went far too quickly. When a placement has been as fulfilling as mine it is easy for me to feel that that's the area I want to work in, but my enthusiasm will last.
I enjoyed the teamwork, the chance to follow up patients, the autonomy and the feeling that I could really make a difference. I look forward to working in the community when I complete my training.

References

  1. Butcher M. Pyoderma gangrenosum: a diagnosis not to be missed. Wounds UK 2005;1(3):84-92.
  2. Knock K, Butcher M. Treatment of an atypical leg ulcer: pyoderma gangrenosum. BJCN 2003:8(S6):19.
  3. Department of Health. Nurse and pharmacist prescribing powers to be extended. Available from: http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleas...
  4. Nurses given full prescribing rights [editorial]. Doctor 2005. Available from: http://www.doctor update.net/du_reference/du_refarticle.asp?ID=16414#
  5. Day M. UK doctors protest at extension to nurses' prescribing powers. BMJ 2005;331:1159.
  6. DH. Supporting people with long-term conditions. Available from: http://www.dh.gov.uk/PublicationsAndStatistics/Publications/Publications...

Resources
Community and District Nursing Association
W:www.cdna.tvu.ac.uk/

Department of Health
W:www.dh.gov.uk