Introduction

The previous chapter has explored what medical nursing is and its principles, however this chapter aims to develop your understanding of what a medical placement is and what it might look like. During your pre-registration education and training you will spend 50% of your programme in placement learning, providing nursing care in a range of environments for patients with varying levels of dependency (Nursing and Midwifery Council (NMC) 2010). Many of you will experience medical placements as part of your programme of study to meet your learning outcomes specific to your field of practice. A placement should be a minimum of 4 continuous weeks of placement to meet the NMC Standards for assessment of learning but you may find that you have a placement base which facilitates a more ‘hub and spoke’ approach to learning. This approach can help you to ensure that you have a greater understanding of the patient journey within your area.

An example of a hub and spoke model of practice learning opportunities could be that you are placed on a medical ward which specialises in the care of patients with respiratory health problems (conditions). Your main placement would be on the medical ward but you might spend time with some of the clinical nurse specialists and teams that might be involved within your patient journey, for example a community tuberculosis team, the pharmacist and physiotherapist.

Historically student nurses would be placed on a medical ward and that would be their medical placement. However, this does not reflect the whole patient journey with regards to their health problems and it is important that you are able to understand what that patient journey might incorporate and mean for the patient. It is also necessary to understand the nursing input within the different medical environments and to ensure that you have placement learning pathways that reflect that journey. All of the medical placements outlined below could be NHS or non-NHS, and universities will have agreements with non-NHS placements such as independent hospitals and voluntary agencies for students to undertake placements there.

It is important for you to understand that not all health care is delivered within the context of the NHS and that patients have choices regarding where they would like to be cared for. You may find that you have some preconceived ideas about independent non-NHS care, however, until you experience a placement, you will not be able to have a real idea about what occurs there and the learning opportunities that these placements can provide. An independent hospital will have many of the placements that an NHS hospital has and will provide medical care within wards, specialist wards, clinics and high-dependency units and will liaise with many other healthcare disciplines. Nursing, wherever it takes place, comes under the guidance and policies of the NMC and Department of Health.

So, what is a medical placement? It could be any of the following:

Medical general, medical specialist and acute medical admissions wards

A medical ward can be defined as an area where in-patients are admitted under the care of a physician for investigation or treatment of medical conditions not requiring surgical intervention. Medical wards can vary dramatically: a district general hospital may have a number of medical wards that care for patients with a range of medical conditions; alternatively, a large teaching hospital may have specialist wards which may have far more specific admission criteria.

The age of the patients cared for on a medical ward will vary. Some organisations will operate an integrated medicine and older people service; this means that patients of any age will be admitted to the ward depending on their medical problem so you may have patients aged 18 and 88 on the same ward. If this is the case, it is important that your knowledge and skills of caring for older people are up-to-date. Other organisations will have dedicated older people's wards, but even where this is the case, some older people may be nursed on medical wards while waiting for a bed on an older people's ward or because of their specific medical needs.

Ward environments will differ greatly from one hospital to another with some wards looking glossy, modern and high tech in comparison to other wards looking more run down. Do not let this put you off – remember, it is the patients and the standards of care on the ward that matter, not how up-to-date it looks.

Most acute hospital trusts will have mixed sex wards rather than female or male wards, but within the wards patients will be nursed in single sex environments. So the ward will be divided into bays with designated female and male bays and separate bathroom and toilet facilities for men and women. Most wards also have a number of single rooms to enable patients to be isolated if they have an infection, for example MRSA, or require privacy, for example at the end of life.

Wards tend to be arranged around either a central nurses’ station or around a number of smaller nurses’ stations. It is at these nurses’ stations that patient notes and forms, care plans, assessment documents, etc. are usually to be found. Wards will also have a treatment or clinical room where medicines and clinical supplies are kept, a stock room where dressings and other supplies are stored and a sluice room where commodes, bed pans, etc. are kept and waste products are disposed. Individual wards will have their own storing systems so it is important that you are orientated to where everything is kept and that you have appropriate access to any storage areas.

Medical wards are notoriously busy areas as often there can be a number of different medical teams attending the ward to see patients at the same time. There may be allied health professionals and medical students using the same placement areas. Patients are usually admitted via the accident and emergency (A&E) department or the out-patient department and some patients will be transferred to your ward from neighbouring wards or hospitals. There also tends to be less of a routine than on a surgical ward, as patients are coming and going to investigations and tests at any time. Patients will attend a number of different departments within the hospital as their conditions are investigated. These are likely to include X-ray, computed tomography/magnetic resonance imaging scan, ultrasound scan, endoscopy, bronchoscopy, out-patient appointments and possibly other hospitals if the investigations required are not provided at the hospital.

You may also find yourself placed on a medical admissions unit. Acute medical admissions or acute assessment units are short-stay departments and sometimes are part of the A&E department. It helps A&E departments to meet their targets and provides an area where patients can be stabilised and a place where further assessment by the team can take place. These are fast paced areas caring for patients with a whole range of medical problems. Sometimes patients are discharged home from the acute medical admissions unit and at other times the patients are transferred to an acute medical ward or alternative setting. A range of patients will be admitted to this ward and the learning opportunities are vast. You will be caring for patients with acute and long-term conditions, for example a patient who has just taken an overdose of their medication or someone who has long-term respiratory problems and has a care package within the community.

Medical high-dependency ward

Medical high-dependency units are often found within acute hospitals and you will immediately notice that the ratio of registered nurses to patients is increased and that there is more technical equipment within the ward environment, for example cardiac monitors, intravenous pumps and non-invasive ventilation. Initially the environment can seem frightening, however the mentors within the area will be used to having students and will usually have a welcome pack and learning opportunities pack that will guide you. First-year students don't tend to undertake placements within this environment and, therefore, students can bring their existing communication and clinical skills and develop them further during their placement time.

Virtual ward

Virtual wards provide support in the community for people with complex medical and social needs and are now being introduced across many areas of the UK. People are cared for by a team of staff as they would be in hospital, however there is no physical building. The virtual ward aims to provide multidisciplinary case management and prevent admission to secondary care (acute hospital wards) and to enhance communication for all those involved in the care. The patient is at the centre of the care. There are different models for virtual wards with some being nurse led and others GP led. Doctors and the virtual ward team will agree who should be admitted to the virtual ward and risk assessments will be undertaken (Lewis 2010).

A community matron or senior nurse will often lead the day-to-day clinical work and office-based ward rounds will occur. Frequency of patient reviews depends on their circumstances and their stability. The ward team will have an administrator, doctors, allied health professionals, health visitors, pharmacists, social workers and community nurses. Patients are discharged from the ward when a patient has been assessed by the whole team. Patients with long-term medical conditions, for example chronic obstructive pulmonary disease, could be admitted to the virtual ward with the aim that they can stay at home but still require acute care.

Intermediate care

Intermediate care is a term to represent a range of services, including integrated health and/or social care, which is agreed by the team to help patients recover more speedily from their illness. The aim of intermediate care is also to prevent readmission to hospital, prevent admission to residential care and to help patients to live as independently as possible (Department of Health 2010). The intermediate care service is normally time limited to 6 weeks and care is provided by a multidisciplinary team. The service aims to help patients to regain their confidence and has an active focus on therapy, recovery and rehabilitation. The service targets patients that may face long hospital stays. There are several examples of intermediate care: community hospitals, hospital at home schemes, rapid response teams, outreach teams, nurse-led units and day hospitals. An example of one of these teams is the respiratory early discharge service which is made up of nurse-led teams who liaise with the community matron. They provide holistic care for the patient with long-term respiratory conditions and will often come into a medical ward to assess a patient to determine whether they could care for them holistically at home and shorten their length of stay within the acute hospital ward. The team also provides health education to the patient at home and liaises with other support agencies.

The aim of the virtual ward and intermediate care is to help patients who have often required a high-intensity use of healthcare services to remain at home longer and to have more choice about their health care. The NHS Improvement Plan (Department of Health 2004) described a new clinical role of community matron and is central to the government's policy for the management of people with long-term conditions.

Medical day care

The medical day care unit (MDU) provides care for patients that require medical treatment/investigations on a day stay basis who will then be discharged home once their care is complete. If there are complications they may be admitted to a ward. Some of these units are nurse led and run by advanced nurses who are able to prescribe and have specialist physical assessment skills and advanced knowledge in specialist areas, depending on the area. Examples of some of the treatments that you might see in day care are the following:

Out-patient department

As a student, you may spend some time in placement in the out-patient department, an area of the hospital attended for booked appointments with health professionals of a particular specialty. Patients will often attend this department as part of their patient journey, either pre-or post-discharge from another setting. The out-patient department is a very varied placement where you will meet patients with many different conditions. Patients are referred to specific out-patient departments by their GP or by their consultant on discharge from a medical ward/acute admissions unit, intermediate care or virtual ward. Other patients may self-refer to independent sector departments if they hold private health insurance. There are many learning opportunities in ambulatory care for example, and the aim is for the student to gain an insight into nursing the ambulant patient and participate in the delivery of care to a wide range of patients of all ages. Placements are varied and can include a variety of clinics, such as dermatology, diabetes and chest clinics.

You will be able to meet some of the key domains for the NMC within the out-patient department, including interpersonal skills and communication. You will need to communicate with many patients each day from a variety of multicultural backgrounds. Some patients may have additional barriers to communication such as deafness or confusion. Many patients are anxious about their appointments and the diagnosis that they might hear, and clinics can over run.

There will also be opportunities to help with wound care and dressings and this can help you to assess and make clinical decisions under supervision (NMC 2010).

Learning opportunities in a vascular clinic

You will also have the opportunity to learn about some of the following:

Learning opportunities within a diabetes clinic

Within diabetes clinics you may be able to experience the following:

Genitourinary medicine/sexual health unit

You may find yourself in a placement that provides a comprehensive sexual health service for both men and women. All services are confidential and free and service users can be under 16 years of age. The units specialise in the treatment of all sexually transmitted infections, including human immunodeficiency virus (HIV) and related infections. They provide a walk-in-and-wait service and departments can be very busy. You will care for patients from all ethnic groups, thus a wide variety of clinical conditions are encountered. Specialist appointment-based clinics can involve male and female survivors of sexual assault, erectile dysfunction, male and female psychosexual problems, treponemal syphilis serology, herpes, hepatitis and warts clinics. The clinics also offer hepatitis A and B screening and vaccinations, emergency contraception and special sessions/advice for gay men. Often psychologists and health advisors will also hold sessions within the clinic and health promotion and health education are very evident within the environments (please refer to the glossary for definitions).

Human immunodeficiency virus services are also included with walk-in emergency HIV services and HIV in pregnancy services, and clinical nurse and midwifery specialists often run nurse-led clinics. Pharmacists provide advice and adherence information to patients and work closely with the team. There is often research nurses and some clinical trials run within these departments.

Patients presenting to the unit will be referred by:

Sexual health units are committed to the following:

Some of the learning opportunities within sexual health units include the following:

Within placement learning pathways there are many learning opportunities. This chapter has so far outlined some of the learning opportunities within the out-patient areas and sexual health clinics to help you see that there are vast amounts that you can learn in every practice placement experience, either as a substantial placement of 4 weeks or more or as part of a hub and spoke placement.

Sometimes it is difficult to understand how the learning opportunities can link to your learning outcomes within your field-specific competencies (NMC 2010). The next section of this chapter aims to help you link those learning opportunities with some of your generic competencies.

Linking your learning opportunities with your NMC learning outcomes

There are four NMC Domains in the new NMC Standards regardless of your field of nursing practice:

Within the above medical placements there are learning opportunities that meet all of the above domains.

Sometimes when you are caring for your patients, you may meet some aspects of all of the domains. For example, if you are a first-year student within any of the medical placements above, you will be undertaking observations of vital signs in a patient's home, a clinic or a ward. While undertaking this skill, you will be incorporating professional values, communication and interpersonal skills and nursing practice and decision making. As a third-year student nurse, you may be looking after a caseload of patients whereby leadership, management and team working may also be incorporated.

On your medical placements, introducing yourself to patients might seem a very ‘common sense’ thing to do, but how you come over in that initial ‘meet and greet’ can determine the relationship and interaction to follow. You might meet some patients only for the duration of their clinic appointment and look after other patients for a substantial amount of time within a virtual ward, intermediate care environment or acute medical ward. The NMC Domains, and therefore your learning outcomes, will focus on incorporating your communication skills and your professional values. How you introduce yourself in a professional capacity should be different from how you would do this socially. Think about what the public expects of you as a student nurse within a medical placement?

As a second- or third-year student nurse, you may find yourself in a more acute environment such as a high-dependency medical ward or acute admissions ward. One of the NMC Competencies for adult pre-registration student nurses is (NMC 2010, p. 6):

Within these acute environments you will easily see how to meet this competency, however you could just as easily relate this to your placement within medical day care or the virtual ward. In medical day care you might be nursing a patient requiring an endoscopy who will require you to care for them pre- and post-procedure. Advanced nursing roles such as the nurse endoscopist and upper and lower gastrointestinal nurses exist and are a great learning resource demonstrating advanced practice within these areas. Within the virtual ward you will be able to use diagnostic skills with patients that you meet and will be able to observe the community matron and nurse specialists demonstrating very advanced diagnostic skills within their case management.

All of the medical placements provide learning opportunities that can be linked to the activities of daily living and Table 2.1 can help you understand how you could meet them across the placement learning pathway.

Table 2.1 Applied learning opportunities: activities of daily living

Here is a real experience of a student nurse in her final placement of her adult nursing programme:

Summary

This chapter has explored the various medical placements and specific learning experiences that you might encounter, however it is also important for you to focus on general expectations in relation to what is expected by the university and the programme that you are undertaking. The next chapter will consider the preparation for your placement, including the practicalities and expectations of your university, the placement and you.