In this short session, students worked with Avery in real time to address their concerns using the underpinning knowledge explored in the pre-work around diabetes management in a holistic way.

Prior to observing the simulation, I felt that my understanding of diabetes management needed further development when it came to the pathophysiology of DKA; however, after deconstructing this with the class it was realised that it is ok to not necessarily know all the answers.

The important part was being able to collaborate with patients to find solutions and taken action, but also to seek additional support from other health professionals where needed (referrals to diabetic educator, dietician).

This directly correlated to standards 4.3, 5.2, and 6.2 of the NMBA standards for practice.

4.3 Works in partnership to determine factors that affect, or potentially affect, the health and wellbeing of people and populations to determine priorities for action and/ or for referral.

5.2 Collaboratively constructs nursing practice plans until contingencies, options, priorities, goals, actions, outcomes and timeframes are agreed with the relevant persons.

6.2 Practises within their scope of practice.

This session re-instilled the crucial idea you don't know what you don't know, but that the main thing is that you seek guidance and know where to find the appropriate resources to support yourself and the patient in their journey, which also ties into standard 4.4.

4.4 Assesses the resources available to inform planning.

It helped to convey what the learning expectations will be for us as students, and what is expected as we verge closer to being fairly autonomous health professionals.

The teaching team also cemented the fact that INC6 is a safe space for students to practice skills and expand their knowledge in a way that way that supports growth without consequence.

1. Reflexive practice is something we will be using throughout the course of our entire nursing careers, and enables us to grow as both individuals, and health professionals.

2. Where we consider our confidence to be in relation to our abilities will fluctuate based on any number of variables at a given time.

   What is important to note is that while we may feel that we are not yet competent, which may cause feelings of anxiety initially, we cannot grow without being inexperienced to begin with. The positive to this though is that with the guidance and support of our more skilled peers (the teaching team), it is possible for us to flourish and grow.

   A concept akin to this is Vygotsky's Zone of Proximal Development, as pictured above.

It was apparent at the time that these skills had not been utilised for quite a while, but felt encouraging in it's own way that we will have sufficient time during the semester to practice and hone in on these skills, including during our clinical placements.

While this workshop allowed us to hone in on the dexterity of skills around drug calculations and administering IV medications, it also heavily re-instilled the importance of concepts around Standard 6: Provides safe, appropriate, and responsive quality nursing practice, namely 6.3, 6.5, and 6.6.

This was demonstrated in the ability to coordinate with our student colleagues initially to delegate tasks, while still working as a team to reach the required outcome of treating Avery's case of DKA by using critical thinking, and prioritising goals of care.

Following on from this, we worked in accordance with the correct policies and procedures aligning to our specific focus of care (fluid administration or drug administration) to inform how we were going to conduct our practice.

While there was an emphasis on utilising the correct, site specific resources from the beginning, towards the end of our class the teaching staff had made a clear point of ensuring we utilise the policies at our disposal.

The emphasis on this was that ultimately, another human's well-being is in your hands and while errors are inevitable in every nurses career, they are definitely avoidable by something as simple as following a policy.

Identifying and assessing the known and potential risks present in a scenario is important so that we know better how to manage them, and can better safeguard our practices to mitigate these risks where possible.

Moving forward, what I will take away from that session is the importance of utilising the available resources to inform planning, and the fact that whether sure or un-sure, to make certain that best practice is followed to ensure we are aligning with the standards set.

Using the whiteboard to map out the concepts around DKA, link systems with symptoms, and clarify the methods of testing used to identify abnormalities was quite useful.

The process of utilising visual guides that were thought provoking and allowed for expansion of concepts in a way that students could guide, helped me to unpack DKA by allowing smaller chunks to come together to construct a more comprehensive portrait of the condition.

This assessment of factors associated with DKA, such as hyperglycaemia, dehydration, ketosis, acidosis, and electrolyte imbalance, and the measurements of these abnormalities helped me to consolidate what was known about the case study, and spurred a stream of thought of how to move forward and plan for care of this patient

(e.g. tests that may be conducted to further inform our input as nurses and what we might expect to see, the affect these symptoms may have on our patient, management with medications/fluids/electrolytes, and psychosocial support and diabetic education).

Of what was taken from this session, it was the importance behind 'Standard 4: Comprehensively conducts assessments' and the necessity as nurses to engage in critical reasoning based on the objective information synthesised from our assessments.

Through the integration of this data, we can support our practice in a structured manner that is accurate and appropriate for the individual.

As with every PEP rotation, it was useful to outline some goals for myself to help provide structure to my clinical actions, which are outlined above. I had outlined these goals in particular, as I feel these are areas that are particularly relevant to the setting and unit learning outcomes overall.

By the end of the first week, it was felt that I had begun to find my footing and engage in some of these goals. This was demonstrated through the utilisation of head-to-toe assessments to inform care, with more focused assessments being undertaken if an area of concern was identified - i.e. shortness of breath noted = undertaking more focused respiratory assessments, including listening to lung sounds, determining interventions such as O2 therapy or inhaler management, and documenting these findings + interventions in DHR progress notes.

The findings of my assessments supported me to begin planning further actions, and how to work with my nurse to achieve the plan of care for each patient.

Conducting, analysing, and actioning these assessments can be correlated with Standard 4: Comprehensively conducts assessments and Standard 5: Develops a plan for nursing practice.

To develop these plans for care, I revised applicable pathophysiology to consolidate knowledge around the complex scenarios I was seeing. This was achieved by devoting downtime on shifts towards researching new information on websites like UptoDate and Life in The Fast Lane (a useful critical care resource recommended by one of the nurses on the ward).

I was beginning to make some connections in relation to what I was researching and how this tied in with what I was seeing on the ward, but this still developing as there was a lot of new information to take in, particularly around new conditions, equipment, and interventions.

I do believe that exposure to all of these new experiences was incredibly worthwhile though, and allowed me utilise some key nursing skills that will be used in future practice.

I felt that I was utilising my critical thinking and clinical reasoning processes more clearly, which was demonstrated in a number of ways, including:

1. Asking more frequent questions around what I was seeing (i.e. why is this condition occurring? why are we giving this medication? how does this condition relate to another? what pathways and interventions are appropriate to this scenario? through what measure will we know if these have been successful?), such as in Standard 4: Comprehensively conducts assessments.

2. Working more cohesively with my nurses, and being assertive in preferences for how to structure care for my patient load, while also working in collaborative effort (i.e. explicitly outlining the plan for the day, doing what I could within my current scope of practice, and identifying when aspects of care extended beyond this and support was needed), such as in Standard 5: Develops a plan for nursing practice and Standard 6.1, 6.2, 6.3, and 6.4.

3. Working with patients to structure their care both during admission, and in a few cases, post-admission (i.e. having more frequent discussions around current care needs, along with goals post-admission and what we could do to support a safe return to the community), such as in Standard 5.2, 6.1 and Standard 7.

This was worked on more consciously following discussions with my CLN around getting the most out of this placement as I prepare to step into the role of being a Registered Nurse with my fellow students over the next 6 months.

I am looking forward to seeing how I am able to further consolidate my knowledge and learning in my final placement for this semester, and soon enough fill the role of Registered Nurse.

In this simulation, a 'student' RN seeks aid from more 'senior' nurses to assist Avery, who is found to be unconscious and unresponsive. Upon assessment, the 'nurses' find empty packaging of an opioid medication near Avery in their hospital bed.

Due to Avery being non-rousable, the nurses in this scenario call a MET and request for the 'student' RN to seek additional assistance also.

The first point that came to mind from this scenario was the importance of our assessment skills.

In this scenario, the students roleplaying excellently demonstrated their A-G assessments. This was done in part through verbalising the findings of the assessment, but also through the interventions taken (i.e. moving pillows from behind the head to ensure the patient airway is not occluded).

What this scenario highlighted in particular was how assessment tools underpin all our other actions, and how these are used to inform practice and planning, such as in Standard 4: Comprehensively conducts assessments and Standard 5: Develops a plan for nursing practice.

Without the data to support our rationale, it is difficult to target the issue with a strategic approach and determine the appropriate course of action. Students in the scenario demonstrated in clear manner their evidence of clinical findings to support the escalation of care, to a MET call.

The second component to this scenario was the importance behind knowing when to escalate care, and more importantly, how to practice within one's scope, such as in Standard 6.2.

As a student nurse, this standard particularly resonates for both current and future practice, as it is easy to second guess ones self due to the level of experience when contrasted with that of our peers, however; the risk of not escalating care could lead to potentially fatal consequences if not addressed appropriately.

What was taken away from this is that it is crucial to be aware of when something falls outside of ones jurisdiction, and knowing when/where to seek additional support from other healthcare professionals.

The challenging component was utilising critical judgement to decide how to prioritise the verbal information provided.

My aim was to outline the most important findings of the assessments, and convey these in a way that informed future actions and recommendations; the ability to do so correlating with Standard 7: Evaluates outcomes to inform nursing practice.

At the time, I could identify that my ISBAR could use improvement, namely in identifying the priorities of care for the nurse taking over. While it was felt that I had identified the key areas to the case scenario (diabetic status/hypoglycaemia and opioid overdose/unresponsiveness), I believe I could have improved my approach towards recommendations for care of this patient (i.e. being more verbally structured in delivering the goals of care).

What was highlighted from this activity was that it will be necessary to continue to practice this skill further on my next placement by taking initiative to be more involved in conducting handovers. Even if not perfect initially, the only way to move forward and improve is with repetition and practice.

The take home message was that we all harbour bias, but what is important is whether this impacts our standard of care.

Our aim should be to work in a just manner that promotes equity, and acts with beneficence (two of our Codes of Ethics as nurses).

We were provided with a series of videos around mental health presentations, that detailed appropriate and inappropriate interactions with patients encountering mental health concerns. As a group, we discussed further the concepts around terminology and how to work with patients experiencing complex mental health scenarios.

What was highlighted from this exploration as a group was the importance of understanding that even though mental health presentations may be challenging at times for both patient and healthcare professionals, we must recognise that we are partnering with patients like any other and utilise our empathy and understanding to support our patients.

Two key standards were taken from these scenarios, which were Standard 4.3 and Standard 6.1.

4.3 Working in partnership to determine factors that affect, or potentially affect, the health and wellbeing of people and populations to determine priorities for action and/ or for referral, and

6.1 Providing comprehensive safe, quality practice to achieve agreed goals and outcomes that are responsive to the nursing needs of people.

These were applicable to the education acquired from this weeks classes, in regards to re-instilling the importance of working alongside patients by putting them at the centre of their care journey, and allowing for joint decision making processes.

Being able to do so means we can provide holistic and appropriate support to those we are caring for, and ensures we validate individual experiences and understand how this informs the actions/behaviours observed.

Students are asked to attend Yasmin and her mother in this scenario, as Yasmin is found to be unsettled and crying.

The complex component underpinning this situation was working with a paediatric patient in distress that did not have the appropriate interventions available (i.e. analgesic medication scheduled). This scenario brought out feelings of inadequacy in relation to not being able to provide provide sufficient support or intervention for the patient and their family, which was a mutually conveyed opinion throughout the class.

The students roleplaying in the scenario utilised some excellent strategies that I felt could be utilised in my own practice if similar situations were to arise, which included: sound analytical and deduction skills underpinning practice, implementation of non-pharmacological interventions/diversion strategies, and emphasising the value of familial input to inform care.

In addition to this, it was noted that there was evidence of the Clinical Reasoning Cycle at play when observing my student colleagues; something which I too would like to continue to reinforce in my future practice as a methodical basis towards how care is approached.

The utility and application of these skills ties into all components of Standard 4: Comprehensively conducts assessments.

When applied to this scenario and future practice, this could be exemplified through the usage of holistic, thorough, and varied assessment tools to provide a basis for practice (i.e. visual observation, physical assessments findings, factoring in comprehensive patient history).

These should be done in coordination with the patient in order to achieve a mutually agreed outcome, and ensure our approach is appropriate, as well as tailored to the needs of the individual.

This session brought out some interesting points for introspection and reflection, including:

1. How to effectively work in partnership with paediatric patients and their families during difficult moments.

2. Communication strategies used with paediatric patients, and how to improve these.

3. Understanding paediatric manifestations of illness.

It was interesting to note some of the strategies used educators when administering medications (i.e. detracting from the seriousness of medical instruments by demonstrating their use and allowing the patient to play with them), which at their core are used to to secure the trust of the paediatric patient and their families.

This also led me to think of how I would apply this within my own practice when encountering a paediatric patient, and how to enhance communication strategies with this demographic, as working with youths is an area that is felt needs further development.

Some key points were taken away for future practice, which were: being aware non-verbal communication cues, utilising paediatric assessment tools to understand variances in pain manifestations, speaking with children at eye level to ensure your presence is not intimidating, and most importantly, involving paediatric patients in their care like you would any other patient.

The ability to work in partnership and collaboration with patients ties in accordingly with Standard 5: Develops a plan for nursing practice, notably 5.2 and 5.3.

5.2 Collaboratively constructs nursing practice plans until contingencies, options, priorities, goals, actions, outcomes and timeframes are agreed with the relevant persons

5.3 Documents, evaluates and modifies plans accordingly to facilitate the agreed outcomes.

The underlying concept that the narrative emphasised was the substantial impact that social determinants of health (SDH) have on health and illness.

As a nurse, it is important to recognise the role SDH play in their interactions with health outcomes, and how this can potentially facilitate or impede wellbeing.

Although the term 'holistic' is used frequently in nursing care, being able to conceptualise the impacts from SDH means we are really beginning to explore the factors in influence healthcare outcomes from a well-rounded standpoint, such as in:

Standard 4.1 Conducts assessments that are holistic as well as culturally appropriate, and

Standard 4.3 Works in partnership to determine factors that affect, or potentially affect, the health and wellbeing of people and populations to determine priorities for action and/ or for referral.

Additionally, understanding SDH allows us to demonstrate empathy by perceiving patients as a whole, and enables us to work in partnership better by providing knowledge of the factors that can support recovery or may potentially impair the process, which allows us to revise our goals and planning of care. This is exemplified in:

Standard 5.2 Collaboratively constructs nursing practice plans until contingencies, options, priorities, goals, actions, outcomes and timeframes are agreed with the relevant persons and

Standard 6.1 Provides comprehensive safe, quality practice to achieve agreed goals and outcomes that are responsive to the nursing needs of people.

This scenario was felt in essence to serve as a reminder to use our A-G assessment as the foundation for care, and to utilise inspection, auscultation, and palpation to support findings. It also re-instilled the processes surrounding when to call escalate care, i.e. calling a MET when the findings of assessments reach the stage that they are beyond our scope of practice.

When breaking down the standards that corresponded with this scenario several were applicable, including:

4.2 Uses a range of assessment techniques to systematically collect relevant and accurate information and data to inform practice.

4.3 Works in partnership to determine factors that affect, or potentially affect, the health and wellbeing of people and populations to determine priorities for action and/or for

referral.

5.5 Coordinates resources effectively and efficiently for planned actions.

6.2 Practises within their scope of practice.

7.1 Evaluates and monitors progress towards the expected goals and outcomes.

7.2 Revises the plan based on the evaluation.

I will take away a few key aspects from this scenario:

1. Patient deterioration can occur quite quickly, and it is crucial to utilise our assessment skills to source the appropriate data to inform out practice.

2. Being able to work in partnership with patients and other healthcare professionals is essential, and helps to ensure that we are able to plan cohesively to achieve mutually agreed upon health outcomes.

3. Flexibility and adaptability are invaluable tools. The ability to be able to navigate a rapidly changing situation, such as in this simulated activity, is something that would take time to develop. I believe that it will be beneficial in my own practice to work towards finding strategies to manage stress associated with these ever-changing situations, and to ensure an open-mind is kept to appropriately address expectations.

It was interesting integrating different components and concerns of the scenario to formulate a comprehensive portrait of our patient (i.e. patient experiencing head strike/neurological symptoms, pain, confusion, and physical trauma), along with utilising critical thinking processes to decipher priorities of care for Steven (i.e. whether to use an anti-metic or analgesic first? Who to refer Steven to? Potential medication interactions?).

These considerations allowed me to engage with content in a way that employed problem-solving and strategic thinking, which I felt was realistic in relation to what is likely to be seen during clinical practice, but also served as a reminder that a whole is only a sum of it's parts.

This was important to remember in relation to:

Standard 4.1 Conducts assessments that are holistic as well as culturally appropriate.

Standard 6.1 Provides comprehensive safe, quality practice to achieve agreed goals and outcomes that are responsive to the nursing needs of people.

The process of undertaking this session has aided me by re-instilling how important it is to be able to perceive our patients through a comprehensive, and holistic lens. To do this, it is also necessary to have a solid foundation of information to inform our clinical actions and decision making.

This was a new way of challenging learning for myself, which was felt to have resonated due to its likeness of real world clinical scenarios. I found that similarly to last weeks sessions, this also allowed me to engage in problem-solving and critical thinking to plan and structure priorities of care.

This was useful, as the reality of future clinical practice will be that these prioritisation skills will be necessary on a daily basis. This ties into adaptability once again also, in that the ability to address a situation as it unravels with composure would require conscious effort and practice.

This skill can be largely associated with Standard 5, notably:

Standard 5.1 Uses assessment data and best available evidence to develop a plan.

Standard 5.3 Documents, evaluates and modifies plans accordingly to facilitate the agreed outcomes, and

Standard 5.5 Coordinates resources effectively and efficiently for planned actions.

Across multiple stations, we were assigned a team leader for our 'shift', who information was relayed to regarding patients on the ward. This required that we understood the patient and scenario, and were able to discuss the interventions that had been undertaken, along with future plans for care.

This process correlated with Standard 5.2 and Standard 5.5:

5.2 Collaboratively constructs nursing practice plans until contingencies, options, priorities, goals, actions, outcomes and timeframes are agreed with the relevant persons.

5.5 Coordinates resources effectively and efficiently for planned actions.

Knowing and understanding all aspects of the scenario was one thing, but being able to verbalise my understanding of the scenario in a way that was concise, yet open enough to allow for collaboration within the healthcare team was something that was felt to still be challenging at times.

I can identify for myself that structuring my explanations is an area for improvement, as these can tend to be quite lengthy without providing additional useful information. This

is something that will need to be improved upon in the upcoming, and final placement, which can be achieved through practicing my ISBAR for the patient load undertaken. I will continue to practice this skill, and aim to enhance my interprofessional communication through purposeful engagement.

Doing so will help be to coordinate better within a team, and will enable me to safely care for my patients by ensuring there is mutual understanding for their care.