Final Entry: Final Placement

Reflecting on my intial entry I found I was fairly accurate in my predictions! The general medical ward was a fairly consistent ward with daily mobilisation and deep breathing exercises, and I managed a 6-8 patient caseload. I was glad to have my own patients in which I could manage independently without having to share patients with Aaron, however he was always available if I needed an extra pair of hands! I was also able to experience ICU this week which I really enjoyed as I had yet to be exposed to the acute medical management and the numerous attachments of the patient. I found it difficult to develop sound clinical skills specific to cardiorespiratory due to the lack of respiratory patients on the ward, often the patients primary problem was reduced mobility but I tried to auscultate as many patients as possible anyway. The aspect of the placement that both drove me nuts sometimes but which I feel very confident in now was discharge planning and the role of a multidisciplinary team. I was a little disappointed that I wasn't being exposed to the exciting side of cardioresp physio as my peers however I developed a sound knowledge of discharge options and the importance of liasing with the MDT. As it was a large tertiary hospital there was an underlying push to free up beds when able and I found that so often once the patient was deemed medically stable the medical team were very eager to D/C the patient whether they were deemed safe from the other disciplines or not. I had a close relationship with the social worker and the OT to organise appropriate follow up care as many patients were originally from home and upon D/C were not fit to cope at home. I feel completely confident to liase with the MDT and the medical team and to express my opinion, I am also aware of all the avenues for follow up care. I think these skills are essential for a physiotherapist working in a hospital setting and are transferrable across all disciplines not just cardio-respiratory physiotherapy. Overall I really enjoyed the placement and I'm itching to start working as a physiotherapist, hopefully in the hospital setting!

Week 5: final placement

Situation: On Monday morning both my supervisor and fellow prac student were on sick leave, the physiotherapy management were unable to find a relief for the morning so I was on my own on the ward and was able to page another physio if I needed help.

Task: My task was to represent physio for the ward's morning handover with the multidisciplinary team and then to see as many patients as I could manage.

Action: Not suprisingly there were 8 new patients on the ward that morning so I found it was essential to prioritise my case load. Conveniently 4 of them were not indicated for physio. I knew that I wasn't expected to see every patient that morning but I felt it was important not to just stick to my patients but see to the priority patients of my supervisor and my fellow prac student as able.

Result: As a result a few of my own patients were a low priority so I managed to see 6 priority patients of my supervisor, fellow prac student and mine collectively. I had the help of a physio with one of the patients as they were an acute stroke with a GCS of 9-10 and I didnt feel comfortable seeing them on my own.

Evaluation: I think I handled the situation well as I didn't get overwhelmed with the initial 16 patient case load I also enjoyed having the independence. I felt confident representing physio in the handover meeting and voicing my opinion in relation to patient management and discharge. I also learnt how to use a pager!

Strategies: I found that patient prioritisation was essential to manage the case load and it is obviously a vital skill required when I will be managing a ward independently once graduated. Good communication is important when liasing with the nursing staff and medical team to ascertain whether physiotherapy is a priority for the patients management.

Week 3: final placement

Situation:
55 yo man transferred to Fremantle hospital for medical admission with diabetic ketoacidosis.

PMHx: type 1 diabetes mellitus, HTN
SHx: lives with wife at home, independent with ADLs
Prev functional status: independent ambulation and mobility with nil aid.

Task: My task was to complete a full physiotherapy assessment of this patient’s chest and mobility.

Action: After completing the assessment I found that he was unsteady on his feet and required O2 to ambulate due to low SpO2 (approx 85% on RA at rest) On subjective questioning I found that he had been walking to the bathroom and back without a frame and without any O2 therapy. He also appeared non-compliant to therapy and didn't understand why physiotherapy would assist him returning home. I spoke with the medical team and learned that the patient must maintain his SpO2 at >94% at rest to be able to go home.

Result: As a result of these findings I educated the patient on the importance of walking with assistance of a frame and oxygen in his current state from a safety point of view for health and also the role of physiotherapy in his management. The patient was very eager to return home and didn’t understand why he was being ‘kept in here’. From a physio point of view my aims were to improve safety with mobility and improve exercise tolerance. Therefore educated the patient on what the SpO2 reading represented on the sats machine and the importance of it for his discharge.

Evaluation: I found that by educating the patient on the requirements for his discharge and the reasons for why I wanted him to ambulate with a frame and O2 proved effective as he had more of an understanding of the reasons behind my actions. He became more compliant with my sessions and was very motivated and focused on improving his SpO2.

Strategies: In the future I will continue to use education and goal setting to motivate patients. I also found that often a patient appears non-compliant because no-one has properly explained the reasons behind the requirements of the patient and so don’t feel like they are being listened to or have any participation in their management.

First Week: final placement

The situation was that I had a patient who had been admitted onto the general medical ward at Fremantle hospital for pneumonia and was 86 years old. She had just been deemed medically stable by the medical team. Premorbidly she lived at home alone and ambulated independently. Since being admitted to hospital she had deconditioned considerably to a point where it would be unlikely for her to return to premorbid function and thus return to living at home.

Task: My task was to conduct a mobility and chest review on this patient to determine their level of function to assist with discharge planning.

Action: Upon review I found that her chest was clear and that she was in fact not at her baseline function. She was mobilizing with a wheeled zimmer frame short distances and required moderate to maximal assistance with mobility. At this stage the patient was at a high level care functional status. I discussed with the patient her options for when she left the hospital as the medical team were under the impression she would prefer to go straight to a nursing home as she was not motivated to participate in rehabilitation to improve her mobility so she was able to go to a hostel.

Result: After talking to her however I found that she would much prefer to go to low level care where she could do things for herself and was motivated for rehab. She realized that for her to achieve this goal she would need to undertake further rehab to achieve low level care functional status. Therefore I liaised with the ward OT to determine an appropriate discharge plan for this patient to optimize their quality of life. We decided that this patient would benefit from slow stream rehab with a transitional care program to improve their mobility so that they could achieve a low level care status and live in a hostel.

Evaluation: I think I was effective with the discharge planning for this patient. By effectively communicating with the patient I was able to determine that the patient was in fact motivated to improve their mobility so that they could be discharged to a hostel rather than a nursing home, therefore improving their quality of life.

Strategies: Strategies that were essential for this situation were good communication and also knowledge of discharge options. I found that there are numerous options to choose from when planning patient discharge and that it is essential to be familiar with all of them as discharge planning is such a large part of our role as a physiotherapist.

Initial entry: fourth placement

This round I am at Fremantle hospital doing my cardiorespiratory placement. I expect it to be quite structured where I will develop a daily routine of seeing approx 6-8 patients a day. I hope that I get the opportunity to experience physiotherapy in the ICU as well as the basic ward work. I expect that the majority of my day will be spent mobilising patients and obviously chest physio to assist with an early discharge. I assume as it being a hospital placement that discharge planning will be vital as soon as the patient is admitted. My main concern is the expectations of me as a student in my final placement, I feel fairly confident with my theoretical knowledge in cardiorespiratory however I am unsure of how well I will transfer it practically. I am to a degree concerned about the fact that there is eight students doing their cardio placement here and what degree of independence we will have. Only because it is my last placement and I'd love the opportunity to work on my own with a full case load however I know this may not be feasible. Overall I am excited to start this placement as it is my final one and I have yet to do any cardio physio.

Final Entry: third placement

On reflection I have really enjoyed this placement, I think due to a combination of being a good placement and livign in the the country for five weeks. In terms of structure, the case load varied with some days having 3 patients spread across the day to others where I had 8-9 patients. The majority of my patients did have back pain but were all completely different in nature, none of them were straight forward! I enjoyed travelling between augusta and margaret river as Augusta was predominantly geriatrics and some hospital work so I got a taste of all aspects. I definitely found the diagnostic process the most challenging part of the placement, as I wasn't used to starting from scratch with no previous diagnosis provided. In some respects your spoilt working on a ward as you usually already know what the main reason the patient is there. I found it at times so complex and challenging and almost a guessing game as you'd trial one treatment to see if it works, and if not try something slightly different next time if they didn't improve significantly. Something I found challenging was the nature of the private practice as patients were booked in and paying to see my supervisor, so at times I a little self conscious as I thought they'd prefer Rob over me as I'm a 'student'. In the end however I didn't have any troubles with the patients and learnt that confidence was the key and they would trust you as a physiotherapist. In all I have absolutely loved this placement and I will definitely keep my options open for rural jobs at the end of the year!

Week five blog: third placement

Situation- An elderly patient booked in because they were experiencing low back pain that they had had for a few years on and off and had worsened over the last week.

Task: My task was to assess this patient and formulate a management program

Action: I conducted a full objective and subjective assessment and found that they were suffering from a mobility issue and was relatively straight forward. I explained this to the patient and outlined my treatment plan for them and soon realised they had a very passive approach to management. They strongly believed that ultrasound alone was what helped and requested it.

Result: I soon realised they had a very passive approach to treatment and that their condition in particular being a mobility issue would not soley be cured by ultrasound. I explained to the patient that the effects of ultrasound and even my treatment in this session were only temporary and that it was most important to continue with exercises at home to maintain the benefits.

Evaluation: I found it challenging to change the patients views on physiotherapy and their symptoms as they were well entrenched beliefs. I realised however that there was only so much I could say or do and that ultimately it was up to the patient to decide whether to take the advice on board.

Strategies: In future I will endeavour to translate my theoretical knowledge into patient friendly language to convey the role of physiotherapy and the importance of self management.

week three blog: third placement

Situation: A patient was referred to the clinic for a mild MCL strain which resulted from an accident at work 3weeks ago. The patient presented on elbow crutches with an obvious antalgic behaviour.

Task: My task was to assess this patient and devise an appropriate management plan.

Action: After a few minutes of taking a subjective history it was clear that there alot more going on then just a mild MCL sprain. The patient expressed a high level of pain from the knee into the foot on the left side. There was no clear relationship between the different pains and it was severely irritable. The patient also had a history of depression and was on workers compensation so there were a few contributing factors. As a result there was very little I could assess objectively as every small movement was painful therefore the was too much risk of false positive results, we concluded that they were experiencing allodynia as a symptom due to the hypersensitivity to light touch. All investigations came back as a mild MCL sprain with no serious pathology evident. Therefore I surmised that there was a large central component to this patient's pain experience.

Result: As a result of these findings, the acute objective was to maintain range of movement and strength and to find pain relieving positions. I explained to the patient that because the injury was now 3 weeks old, the pain that they were experiencing was becoming maladaptive and that it is important to move the knee through bearable pain so they did not decondition. I also monitored their symptoms closely to note any physical exacerbation objectively compared to the subjective reporting from the patient.

Evaluation: I realise that when I first read the referral I assumed it was a fairly straight forward patient. Clearly now I know not to assume anything from a referral letter and that although physical finding may be relatively mild that doesn't translate directly to the patient's experience. This patient was in a lot of pain and yet it appeared it was a mild mcl strain with minimal bruising and swelling.

Strategies: In future I will not presume a patient's condition from a referral form or previous investigations. It is important to do make an educated decision on a patient's presentation after a thorough subjective and objective assessment. I've also realised the importance of education in a central pain presentation or one with yellow flags as it is vital to reassure and explain pain to the patient to prevent catastrophisation.

third placement- week one blog

Situation: This week I had a patient who was 10 weeks post subscapularis tendon repair, he had been seen previously by another physio student in which I was taking over from.

Task: My task was take over the rehabilitation of this patient from a previous student and progress his home exercise program.

Action: I had little time to prepare my session with this patient so I began with a brief subjective and objective assessment and then continued on from the previous student's treatment plan. To conclude the session I went over his home exercise program and gave him another exercise to try.

Result: As a result of knowing little about the patient the session didn't run smoothly and I constantly had to refer to the patient's previous notes to keep on track. I stressed that the patient may become impatient if I took too long reading over their previous notes as it may look like I was incompetent.

Evaluation: I felt that the session was very disjointed and I didn't feel confident that it was effective for the patient. I felt that I didn't know the patient's history thoroughly and therefore was unsure how best to progress the treatment session and home exercise program.

Strategies: In future if I'm restricted for preparation time I will take the time during the appointment to fully comprehend the patient's history and not stress that they will become impatient. It is more important to take the time to devise an appropriate treatment plan so that is beneficial for the patient.

third pacement- initial entry

This round I am in Margaret River for my rural prac and it is a musculoskeletal placement. I am looking forward to this placement as I have yet to do musculoskeletal and I'm interested in learning about how a private practice functions. I assume that I will have 4-5 clients a day and that a large majority of those will have back pain. I will also be conducting an exercise class each week for the senior citizens so I will have an opportunity to put my gerontology experience into practice as well. This placement will involve time spent at both the Margaret River and Augusta practice so I am looking forward to getting a taste of both areas. With this placement I'm mainly concerned about the diagnostic process and whether I have sufficient theoretical knowledge to link up my subjective and objective assessment to come to a diagnosis. I'd like to be able to get into the habit of having a fluid assessment process to make the diagnostic process easier. I know that this will all come with practice so I'm definitely going to make the most of this opportunity, and also enjoy the country life!

final entry- prac 2

On review my intial expectations of the placement's structure was fairly accurate, however I only spent three mornings a week on the ward. In this regard I would have preferred to be on the ward every morning for routine purposes and also because I missed out on three mornings due to the easter long weekend and a sick day. In terms of content this placement was predmoninantly focussed on antenatal and postnatal care and I sat in with my supervisor on the incontinence appointments.

I found that I had a good relationship with my supervisor and didn't find her intimidating, it was important to be able to take constructive criticism and also accept that they had a particular way of doing things which they wanted me to follow. It became evident early into the placement that education was pivotal and as predicted the ability to translate information into layman's terms was very important.

In conclusion I really enjoyed this placement as it offered a unique aspect to physiotherapy which I could definitely see myself specialising in. Throughout the placement I found that to be an effective women's health physiotherapist requires you to have a large and multifaceted scope of knowledge in the area. I feel that as a new graduate it would take some time to acquire the required knowledge to be successful and that further education such a masters or post-graduate degree is essential.

Post 3- 2nd placement (assessment)

Situation: A lady who is 25 weeks pregnant presented with a right subluxing patella, right hip pain and lower back pain. On subjective questioning it was evident that her subluxing patella was her priority for treatment followed by her hip pain and then her back pain.


Task: Conduct a full assessment to ascertain the cause of the above issues and provide a management plan for her to follow independently at home.


Action: I conducted a subjective assessment for each pain however I focussed on her subluxing knee as it was of most concern to the patient. After thorough questioning of the knee subluxation and associated pain I realised that she would benefit from musculoskeletal outpatient care rather than women's health as she was allergic to taping and would likely benefit from a brace. I then went on to question her about her hip pain and back pain and through doing this she realised that her back was actually quite irritable however she had been too focussed on her knee to realise.


Result: As a result of subjective questioning I realised that the back pain that I had subconsciously disregarded would be the focus of this treatment because I felt it was influencing her hip pain aswell. After objective assessment she was found to have SIJ pain and after trialling a SIJ belt the pain instantly reduced.

Evaluation: On reflection I realise that my instant prioritisation was almost detrimental to the patient. Although the patient was most concerned about her knee did not mean that her back pain was any less signficant, and through subjective and objective assessment I found that it was quite irritable. So as a result the patient gained some benefit from the session as although I didn't treat her knee subluxation I did improve her backpain which instantly improved her mobility.

Strategy: In future I will endeavour to explore each pain thoroughly before I make my priorisation for treatment because I could potentially overlook important aspects of the patient's presentation.

Round two- post 3

Situation: Every tuesday morning there is a community post-natal fitness class run in Girawheen for women 6weeks post-partum onwards. It is a circuit based program with 3 levels of difficulty to cater for all and the women are able to bring their child along.



Task: Today my task was to run the aerobic warm-up for ten minutes at the beginning of the class.


Action: My warm-up consisted of several aerobic components to two tracks of music, it was important to count in the next progression so the transition between steps were fluid.


Result: I found it hard to get in time with the music intially because I had not familiarised myself with the music sufficiently. Therefore the first few steps were out of time and the women found it hard to keep in rhythm. This resulted in a few having to stop so they could get back in time with the music. The second track of music had a much clearer beat so I managed to get back on track and lead the class.


Evaluation: On reflection the first part of my routine was out of time and this made it hard for the women to effectively warm up. This was due to my poor preparation as I didn't realise that the first track had a confusing beat and as a result it looked bad on my part as I was unable to lead the class sufficiently.


Strategies: In future I will practice my routine with the music thoroughly beforehand so I am familiar with the beat and I can easily keep in rhythm. In doing this I will be able to effectively lead the other women in the warmup as they will be able to follow my lead and keep in time resulting in a full and efficient warm-up.

Topic One (2nd placement)

S- My patient was referred to women's health outpatients clinic for lower back and buttocks pain, she was 38 weeks gestation and spoke little english however her husband was present to translate.

T- My task was to assess this woman and devise strategies for management of her pain. I only had 30mins due to a double booking.

A- The subjective assessment took longer than I had anticipated due to the language barrier. With the objective assessment I was only able to assess her back and buttock in sidelying and sitting positions due to the woman being 38 weeks gestation. I found that changing positions caused her pain and discomfort.

R- Eventually I was able to determine that the pain was coming from an overactive piriformis muscle in her left buttock. However this was after tedious subjective questioning and extensive objective assessment. Due to my lack of planning my patient had to keep moving around on the plinth so I could achieve the appropriate position for assessment.

E- On reflection I found it difficult to communicate with the patient due to the language barrier particularly when searching for the pain objectively. I also felt that the sequence of my objective assessment was not efficient as I had to get the patient to move into different positions continously which caused them some discomfort and possibly could have exacerbated their pain.

S- I think with practise my communication through an interpreter will improve but I will endeavor to simplify my questions and instructions to make it as clear as possible to translate to the patient. Also by taking a minute before I begin my objective to organise my assessment so that I can achieve all my tests in one position and then change will help with the efficiency of my assessment and also make it more comfortable for my patient.

Initial Entry (round two 4th year prac)

My second practical placement for this year is at Osborne Park Hospital in the Women's Health area. In terms of structure I think the placement will consist of a mixture of inpatient and outpatient clients both individually and in an exercise class setting. I think that the morning will be spent on the ward assessing and managing inpatients, and in the afternoon I will have student outpatient appointments and an exercise class on some days. I think the majority of my patients will have incontinence issues and the rest will be antenatal and postnatal.

I think in the first few days I will be shadowing my supervisor to learn the expectations and protocols of a women's health physiotherapist. I hope that by the end of the week I will have my own case load which I can manage independently. I understand as a student in the women's health area that there will be things that I won't be able to do such as internal examination so I hope that I will have the opportunity to observe this instead. I predict that I will be able to observe a birth at some stage aswell.

I expect that my role as an educator is a vital part of women's health physiotherapy. Therefore my ability to translate my knowledge into layman's terms will be essential. I am concerned whether the depth of my theoretical knowledge is adequate as I am unsure of the expectations of me as a women's health student. I am also concerned of my ability to put this knowledge to practical use as we only spent half of a semester practicing and I have since not put it to use. Lastly and although petty I am concerned about getting along with my supervisor, unfortunately I have heard from past students that she is very intimidating and intense. I worry that I will be intimidated and constantly nervous under her supervision which will affect my performance. However I am not to going presume anything and that the opinions are completely subjective, I will also have a tutor for support if there is are conflicts. Overall though I am excited to start this placement as I really enjoyed the unit at university and now have a unique opportunity to gain hands on experience in the area.

Final Post

On review, my initial expectations of the placment structure and my role within this were met. By the end of the 5 weeks I was managing a moderate caseload and conducting independent inpatient and outpatient appointments- I very much enjoyed the independence and ability to devise rehabilitation programs for my patients. I found that my theorectical knowledge was one of my strengths and that I had more trouble with the practical analysis of a patient. I've come to realise that this will only improve with practice and observing real patients. I thoroughly enjoyed having an inpatient and outpatient caseload mostly due to the fact I was exposed to both the acute and chronic stroke population. I would have liked to have had experience with other neurological conditions however due to the nature of the ward and outpatient refferals this was not applicable.

As predicted the patient's rehabilitation was conducted from a multidisciplinary approach where I found myself constantly liasing with other team members to ensure an efficient yet safe discharge. It was evident that a patient's rehab is multifaceted and requires the co-operation of many professions to ensure that the patient has the maximum potential to recover. I was pleasantly surprised to see that physiotherapists played a very important and pivotal role in deeming a patient safe for discharge once they were medically stable. Often in the ward meetings the medical consultants would look for our opinion first in terms of discharge planning and what timeframe is predicted before the patient is safe to go home. Overall, I found that physiotherapy has high integrity within the neurological rehabilitation setting and that our role in preparing patient's to be safely discharged home and aiding them in returning to better function is pivotal in the multidisciplinary team.

Topic 3: evidence based practice and intervention

Situation: My patient was referred to outpatient's clinic for impaired mobility and dynamic mobility due to stroke in 2000. The patient's goals were to improve efficacy of functional mobility ie. rolling, supine to sit, sit to stand, and able to get off the floor if falls over. Pt was found to have learned non-use on the L) side as the L) UL was functional however the pt did not percieve it to be part of themselves nor believe they could functionally use it.

Task: My task was to devise a program to achieve the patient's goals and also address the learned non-use on the L) as I believed it was greatly impacting their functional mobility.

Action: I researched constraint induced movement therapy in correlation with learned non-use to find evidence on the benefits and limitations for the treatment approach. I found that my patient was a good candidate as they were reasonably high functioning in the L) UL and was also a chronic stroke patient in which the majority of the studies were conducted on. I applied the principles of the CIMT approach such as forced use of the L) UL in functional activities-rolling, supine to sit, assisting with STS, putting shoes on and weight bearing activities through the L) UL to prove to the patient that their arm could indeed be used functionally.

Result: I found my actions to be successful because by the end of the session the patient was using the L) uL consistently in functional activities particularly during STS. The patient was very interested in the CIMT and the research behind it so went home to follow it up. The pt also began to recognise the functionality of their L) UL during WB exercises and was suprised to find that it could support weight and also aid with mobility thus changing their attitude towards their L) UL.

Evaluation: Overall I believe my intervention was beneficial for the patient and indirectly targeted their goals. I think my strength was being able to adapt the principles of CIMT to my patient so it was relevant and beneficial in obtaining their goals. I think my weakness was that I wasn't strict enough with the protocol, for instance the patient tended to use the R) UL after continous failed attempts with the L) and I occasionally would allow him to do so. I think for this treatment approach to be more effective I need to be vigilant with the forced use concept and strongly discourage compensatory use of the R)UL during the treatment session.

Strategies: A strategy I could use to avoid this would be to place the R) UL into a restrictive device to completely discourage use such as a sling or rigid mitt. Also by explaining to the patient the importance of not compensating with the R) UL may engrain the principles better and encourage better performance at home aswell.

Topic Two

Situation: Patient with Lateral Medullary Stroke on the Stroke Rehab ward who requires physiotherapy to improve his ambulation so he is safe for discharge. He has L) sided weakness and leans to the L) in standing due to impaired vertical alignment.

Task: My task today was to continue rehab with this patient to improve his quality of gait and transfers.

Action: I spent the morning working on foot placement and weight shift to the R) during gait and dynamic balance. The session was shortened due to a mild onset of nausea and exacerbation of longstanding right hip pain during exercises. The patient had complained of nausea over the past few days so I decided it was safer to shorten the session for today and talk to his doctor about what the possible source of the nausea was.

Result: By the end of the session the patient’s gait had improved with an increased stance phase on the R) LL and larger steps with the L) LL. He reported that his confidence with walking had improved as well. After consulting with the Doctor I found that the nausea was a likely symptom from the stroke or a symptom from their medication and was still safe to exercise.

Evaluation: I feel that the intervention I conducted targeted the patient’s impairments and activity limitations. However the intermittent nature of the session meant that it lacked efficiency and discharge would be prolonged if sessions were continually shortened due to complaints of nausea.

Strategies: The next session with this patient I will educate them on the likely reasons for the bouts of nausea. I will inform him that as long as the nausea is bearable it is important to continue with therapy to help him recover his function efficiently and that by working through it can help to manage and control it. Thereby ensuring that he is discharged as early as can be.

Topic One: Communication/Assessment

Situation: Today there was a new patient admitted to the stroke-rehab ward and therefore required an initial neurological assessment.

Task: The task set by my supervisor was to conduct a subjective assessment with this patient as there were gaps in the medical notes in regards to history of presenting complaint, past medical history and social history.

Actions: I spent the afternoon conducting a subjective and objective assessment of the patient.

Result: After conducting the assessment I gained an insight into the patient’s history leading up to admission to hospital. I also had an understanding of the communication strategies that I needed to use to conduct a time effective session.

Evaluation: I feel that I conducted an adequate subjective assessment and extracted the information that I required. However the patient’s responses to my questions were quite long winded and tangential. I found myself struggling to refocus the conversation to my subjective aims without interrupting the patient and seeming rude. On completion I felt that I had the information that I required although it took a lot longer than I had intended. On reflection it was positive that the patient felt comfortable to talk to me unreservedly although I feel that it wasn’t a time efficient method of conducting a subjective assessment. I need to remember that although I want the patient to feel comfortable and at ease in a patient-therapist relationship, I also have a role as a clinician to extract the necessary information in a timely manner to ensure that further assessment and intervention can be conducted.

Strategies: In future sessions with this patient I will endeavor to use closed ended questions. I will also try to be more assertive with refocusing the conversation and time questions when there is a pause in a response that I feel is going off track. In doing this I will need to be conscious of not coming across as being rude and insensitive to the patient's response. I also believe multi-tasking during the session will be beneficial such as allowing the patient to continue talking however continue with the objective assessment or intervention whilst doing so.

Initial Entry

My first placement is at Swan Kalamunda Health Service for my neurology placement. I expect this placement to be predominantly stroke orientated with the exception of an assorted neurological conditions in the outpatients department. I expect/hope that as a fourth year I will have more independence with managing a case load and that I will have the opportunity to eventually work on my own. I think there will be a heavy emphasis on working within a multidisplinary team, as many professions will be working towards the goal of discharging the patient.

In terms of structure I think that I will participate in both inpatient and outpatient rehabilitation and this I am excited for as I have yet to experience an outpatient setting. I think that I will have the chance to run independent outpatient appointments. As a student in the facility I think my role will be intially observing and learning practically the expectations of my supervisor, I am on prac placement for the learning opportunity but I also understand that as a student I am also there to help out the supervisor and other team members to manage the case load. I am both nervous and excited to start my first practical placement for the year. I am mostly nervous about the expectations of me as a now fourth year graduate and whether my theoretical knowledge will be easily transferred into practical/clinical skills.