Case 10: Prioritisation and managing stress: Expert Comment by Dr Jess Bilaney & Dr Beth Walker

Thanks to everyone who contributed to the discussions about Carla an FY1 who had a stressful day and surgical on call.

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You can see the highlights of the discussion on Twitter in the storify.

This week’s question setters & experts were Dr Jess Bilaney & Dr Beth Walker, Clinical Teaching Fellows at UCLMS.                                                                     

Information available at the start of the week:

A new FY1 doctor, Carla Rose, is on her first surgical on-call day shift from 8am – 8pm. The shift starts with a busy ward round with her registrar and SHO. Carla documents, on her patient list, the jobs to be completed for the overnight patient admissions. From 5pm – 8pm Carla is covering three surgical wards on call.

Carla works hard throughout the day to try and complete the post ward round tasks , as well as helping to clerk in new patients who also need new investigations organising. Her bleep has been sounding endlessly all day.

By mid afternoon Carla is overwhelmed with multiple discharge summaries to be completed, cannulas that need inserting, a patient that has a low urine output and an angry relative. She bleeps her SHO for help but he does not answer as he is in theatres. At 3pm she calls her mum in tears, she hasn’t had lunch and feels she can’t cope.

Carla struggles on but is aware that surgical handover is looming at 8pm. She still has four cannulas to insert, three drug charts to re write, some IV fluids to prescribe and has just had two bleeps asking her to come and see an unwell patient and a patient that wants to self discharge.

Carla makes it to handover late with the jobs pending. She tells the night FY1 she will stay later to finish of the jobs from the day take. It is now 9.30pm and she is still at work completing the jobs she feels need to be done before she goes home.

Question 1: Explicitly list the tasks that Carla has left just prior to handover to in order of priority and explain your reasoning

Further information released during the week:

Further Information about Carla’s Pre Handover Tasks.

1. The Unwell Patient
After asking the nurse for more information: Day 1 post operative (total hip replacement) 72 year old lady. No evidence of bleeding.Vital signs were normal, urine output had been normal until 2 hours before, still has a urinary catheter in situ. Patient was complaining of supra pubic discomfort.
2. The Patient that wants to self discharge
Mr Brown, an 80 year old man, has been admitted after a fall with head injury and he wants to go home as his cat is there and hasn’t been fed.
3. IV fluids to prescribe
Two patients on two different wards. One is just starting to eat and drink and the other has severe pancreatitis and is nil by mouth.
4. Cannulas
The nurse would like two cannulas for patients who are going to theatre in the morning, a patient who is having a sliding scale and the patient with severe pancreatitis.
5. Drug charts to be re written
Two patients who are recovering from total hip replacements. The charts run out of space for the nurses to sign for prescriptions (at 6am tomorrow).

Further questions discussed on Twitter:

Question 2:  Who can Carla ask for help with her workload?

Question 3: Where resources and services are available to help Carla manage her stress?

Expert Comment

Key points:

  1. If you ever end up feeling out of your depth as an FY1, there should always be someone to ask for help.
  2. It is important to act early and escalate your concerns if you cannot get hold of the designated colleague or seniors for advice.
  3. You are far less efficient when you are tired or hungry so taking a break is extremely important!
  4. If you’re feeling stressed or upset about work – tell someone! Talk to your peers, friends, clinical or educational supervisors for support and help.
  5. Being able to handover tasks at the end of your shift is a vital skill for a junior doctor.

Resources:

Managing Stress in FY1

Helpful Resources for the SJT (Situational Judgement Test)

Dr Jess Bilaney & Dr Beth Walker say:

This was an interesting scenario which brought out some important aspects around managing stress and prioritising in FY1.

Stress

Stressful situations such as a mounting workload, your bleep going off seemingly every minute and not always being able to get hold of who you need, are ones that almost all FY1 doctors will face. It is how you handle these situations that makes the difference. In this situation, Carla needed to ask for help, both for reasons of patient safety and for her own health and welfare.

Skipping breaks may seem like a way to save time, but consider how tired and sluggish you feel if you haven’t had anything to eat all day – this is going to do neither your patients nor you any favours! While it may not always be possible to take a nice, leisured lunch break – it is vital to make sure you give yourself time to have a sit down and eat and drink something.

Prioritising

When prioritising tasks it’s helpful to break down what you have to do into smaller chunks and produce a list. Your number one priority is dealing with patients who have become more unwell, no matter what other pressures are being put upon you by other people.

Finding out crucial information about the tasks to be undertaken will help you prioritise rather than become overwhelmed and also to distribute appropriate tasks to others.

Working with others

There should always be someone to ask for help – for example, your CT/ST (SHO), registrar, consultant, clinical or educational supervisor. It is important to act early if you are feeling out of your depth or like you are facing an impossible workload. If you are not able to get hold of someone via their bleep, as with the CT in this case, then you need to tell someone to ensure patient safety is maintained. In this case, Carla could have considered going to theatres to let her CT know she needed his help on the wards, or she could have bleeped her on-call registrar to let them know of the situation.

Being able to handover tasks to a colleague at the end of your shift is a vital skill for a junior doctor. It’s not failing or showing weakness to need to handover certain jobs for the next on-call FY1 to do – this is far safer than staying for hours after your on-call was meant to finish trying to get everything done. In this situation Carla should have prioritised tasks she thought needed to be done during the night shift and handed these over to the night-take FY1, rather than staying on at work far past her shift had ended to try and get everything finished.

The more prepared and supported you feel as an FY1 doctor, the easier you will find it to cope with stressful situations.

Situational Judgement Test (SJT) – UCL Student Information

Introduction

As part of the selection for the Foundation Programme you are required to sit a Situational Judgement Test. You will not have taken this type of exam before so it is important to understand what the questions are testing and how it is marked in order to prepare yourself. No additional knowledge is required for the SJT and it is not something that is easy to revise for; you will need to demonstrate skills and attributes of a trustworthy professional in order to answer the questions. SJTs are new to the Foundation Programme but are not new: they have been used for GP selection for several years. They are also used in other professions and industries as situational judgement is an important skill in many contexts.

Answering SJTs

The skills you are aiming to demonstrate are often complex in nature. Demonstrating them relies on your ability to rapidly take in a number of contextual factors, weigh up the various options available to you and come to appropriate decisions. There is no single right answer to these questions, but in answering you should consider how the options relate to the professional attributes expected of an FY1 doctor.

These include:

1. coping under pressure

2. effective communication

3. professional development and continual learning

4. organisation and planning

5. patient centred care

6. problem solving and decision making

7. professionalism

8. self awareness and insight

9. working effectively as part of an MDT

10. honesty and integrity

The principles of Good Medical Practice, as outlined by the GMC, will also be highly relevant.

http://www.gmc-uk.org/guidance/good_medical_practice.asp

All of the scenarios will be based around a situation that could be encountered by an FY1 doctor. There are two formats of questions:

1. Ranking

◦ you will be asked to rank all answers from most appropriate to least right appropriate

◦ 2/3 of the paper will be ranking questions

2. Selecting

• you will be asked to select the three most appropriate answers from a list

• 1/3 of the paper will be selecting questions

• you must only select three answers. If you select more you will score nothing for that question

Top tips for performing well in the SJT

In general:

• Re read relevant documents like the GMC’s Good Medical Practice, and the person specification for an FY1 doctor

• Remember that the questions do not have clear right and wrong answers, but ask you to consider which answers are most/least appropriate

• Keep an eye on the time, and make sure you answer all the questions

• Read the stem of each question carefully before you look at the possible answers

• Remember that in all of the questions you are a FY1 doctor

For ranking questions:

• Ranking questions usually take longer to answer than selecting questions so make sure you allocate an appropriate amount of time to answer them

• Read all of the options before you start ranking

For selecting questions:

• The order of your three answers is irrelevant, so exclude the inappropriate answers and when you only have three left choose these as your answers

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