My placement comes to an end.  As ever, I have encountered many interesting people and situations and experienced a wide range of emotions from elation through to despair.  I have learned a lot and realised how much more I need to learn.  The kindness and patience of the majority of staff have made the difficult task of adapting to a new placement a pleasure, only marred by a few who seem to have forgotten that they too were once students.  And what of my quest to back up my practice with nursing research?  I have tiptoed like a child into the boxing ring of evidence based healthcare and come out after round one with a bloodied nose before even swinging my first punch.  But I am still on my feet and will hopefully be a little wiser when I return for round two.

‘Ring for the paediatric nurse,’ bellows Christine trying to make herself heard over the top of the heartfelt screams of 5 year old Thomas.  Thomas has had 5 teeth removed, and has just woken up in the recovery area spitting blood metaphorically and literally.  We are amazed at his strength as an anaesthetist and 3 nurses’ combined efforts only just manage to stop him from launching himself off the trolley.  I rather pride myself on having a way with children, so on finding Thomas’s favourite teddy bear on the trolley  I confidently approach the angry and frightened child. ‘Look Thomas, it’s Barney bear,’ I say in my most soothing voice.   Thomas fixes me with a glare of stunning malevolence and yells ‘I WANT MY MUMMY’.  Helen, the children’s nurse arrives to a combined sigh of relief, and in seconds Thomas morphs from demon in child form to the embodiment of peaceful angelic vulnerability. 

During a quiet period in the day surgery list I take the opportunity to continue my search for more recent evidence about postdural headaches.  Charlotte, a recently qualified nurse, looks over my shoulder.  ‘I suppose you have some reason for looking at that?’ she says accusingly.  I quickly mutter something about needing it for a college essay.  Why do I feel so embarrassed to be caught looking up nursing research?  Despite the emphasis on evidence based care in nursing courses and within the UK nursing code of conduct, even those recently qualified often regard it as an assignment to be passed at university but not really relevant to practice.  I still believe that as nurses we can and should be putting evidence at the core of our practice, but there is clearly a hill to climb in empowering, educating and changing attitudes to achieve this.

Today I try to engage nurses with my research findings regarding bed rest after lumber puncture.  I am aware that this might not be the most riveting of conversational openings, but I am still quite disappointed with the result.  Some of nurses I speak to are not at all sure why they ask patients to lie down after their procedure, whilst others reply that they think it is something to do with getting headaches, but are unable to give any more details.  I wonder who is dictating this care plan, and am told that it’s just what everyone does, and they expect it is documented in some procedure somewhere.  I am assured that it will be the consultant who will have ultimately specified the requirement.  Several nurses admit that they do not know much about evidence based practice, and would not know how to go about finding relevant evidence.  I am left with the impression that nurses are not expected to question practice; our role is to carry out procedure and process as laid down by the greater system over which we seem to have little influence.  I can see the logic in this.  If every nurse were to develop their own protocols, then the standard of care delivered would be even more of a lottery than it is now.  It makes sense that there are proper pathways for incorporating relevant evidence into practice.  Perhaps I need to need to find out more about how this process operates.

I arrive in the day unit to see Dave limping down the corridor.  ‘What happened,’ I ask.  ‘I got knocked down by a car and spent the night in the emergency department,’ he grins.  He denies that centurion was in any way connected and nonchalantly hobbles off down the corridor.

I have a focussed clinical question!  Whilst working on the pain list, I note that patients receiving epidural steroid injections in their spine have to lie down for 20 minutes after their injection.  I am told that this is to reduce the chances of them developing a headache following their procedure and that they used to lie down for much longer.  I decide to look to see if there is any evidence to back this up.  My question is “For patients undergoing lumbar puncture does bed rest result in reduced incidence of headache compared with no bed rest?”.  Searching for “lumbar puncture and bed rest and headache” in Evidence Based Nursing (http://ebn.bmj.com/search.dtl), I find an article that seemed to answer the question “McArthur J (2002) Longer bed rest does not prevent more postpuncture headaches than immediate mobilisation or short bed rest. Evidence Based Nursing. 5;87”.  I am pleased to find this article because I know that only quality research is summarised in this journal.  In addition, the title of the piece answers the question immediately, and the article itself consists of an easily read synopsis of the relevant research (in this case a systematic review of randomised controlled trials) without too much unnecessary detail.  The article also includes a commentary which provides a simple explanation of the research and its application to practice.  The conclusion appears to be that contrary to the previously perceived wisdom on the subject, there is no evidence to suggest that bed rest after lumbar puncture reduces incidence of headaches.  Flushed with success I print both this article and the longer systematic review to which it refers in order to examine them more carefully, and resolve to search for further more recent evidence perhaps in some of the bibliographic databases (for example Medline). 

Today I have a day off, and enthusiastically start to look for a ‘revolutionary’ piece of evidence to introduce into the day unit.  I know that Evidence Based Nursing (http://ebn.bmj.com) and The Cochrane Library of Systematic Reviews (www.cochrane.org) are good places to look for quality evidence, but I don’t really know what I am looking for.  I notice that the majority of the reviews concern drug treatments, or the efficacy of certain surgical procedures and that as a student nurse I am not in a position to influence either.  I find an article about knee surgery.  For one awful moment I have visions of trying to confront Mr Shetland the orthopaedic surgeon with my piece of evidence.  Mr Shetland is not an easy man to work with.  He is an excellent surgeon I have no doubt, but I have watched him reduce his theatre staff to tears as he bombarded them with a sustained barrage of criticism.  Rumour has it that his reg walked out on him.  Trying to discuss my piece of evidence with him is unthinkable.  This is an ignominious start to my aspirations to spread the word of evidence based practice.  I have fallen before leaving the starting blocks.  I spend another hour scanning through endless articles about the merits of using indigenous health care workers in treating indigenous children with asthma and other esoteric topics before realising I am wasting my time.  I remember being taught at university about the necessity of a focussed clinical question, and realise that that is what I need.

Sunday

Tomorrow I start my new placement at the local hospital.  For the next eight weeks I will be nursing student in residence in the ‘Day Unit’, and am looking forward to getting stuck in to some practical nursing after all the essays and course work.  I am also planning to try to put into practice some of what we have been learning about evidence based practice at university.  I feel a little aggrieved that once more I do not have a ward placement.  Half way through my course, and my tally is two nursing homes, an outpatient department, and one seven week placement on a surgical ward.  I know that nursing is becoming less and less about hospital wards, but I am starting to dread meeting my fellow students and hearing them talk so knowledgeably about things I have barely heard of.  I console myself with the thought that we probably all feel the same, each suspecting that others are getting better experience than we are.  Still it’s scary to imagine qualifying and being let loose as a ‘real’ nurse any time soon!  I have heard nurses saying that it all comes together in the third year – I hope so.

Monday

I must say I enjoyed my first day.  It involved managing a list which consisted of three gentlemen for vascular surgery.  I struck up a good relationship with all three, relieved after my previous placement in outpatients to spend more than a few moments with each patient.  Managing the list seems to involve admitting the patients, taking them down to the day theatre when called for, collecting them afterwards, and monitoring them during their recovery through to discharge.  It does not seem too difficult.

Wednesday

My first clinic was not representative.  This is hard work.  I fondly remember the coffee breaks and business meetings of my previous career in IT as I shift my weight from one aching foot to the other.  What possessed me to throw away a good salary and a nine to five job for this?

Friday

I had my initial interview with my mentor today.  She oozes calmness and experience, and tells me I am doing well.  I am not so sure.  I am in awe of the staff nurses’ multitasking abilities.  In my previous career I kept a ‘to do’ list which I reckoned was a pretty reliable and efficient way of organising myself, but this is different; there are hundreds of things to do every day, and they all seem important.  I realise that you are not remembered for the ninety nine things you remember to do, but for the one that you plain forgot about.  I have had decent results in my exams and assignments at university, but sometimes I just don’t feel clever enough to be a nurse.  The experienced nurses manage it all so effortlessly.  How will I ever be able to do that?