STARES 1

SITUATION:

A 19-year-old female patient was admitted to the ICU at Fremantle Hospital following an overdose of Seroquel, an anti-psychotic commonly prescribed to people suffering from bipolar disorder. Within the patient’s notes was a detailed psych examination from her psychologist. This patient had an extensive history of family sexual and physical abuse, neglect, drugs and alcohol, witness to suicide of a close family relative and episodes of insomnia and paranoia. On presenting to ED she was intubated and administered charcoal in an attempt to preserve her organs and bodily functions. Within the ICU the patient had multiple attachments including; invasive SIMV with constant PEEP of 8kpa and 100% FiO₂, cardiac monitoring, Noradrenaline to support heart function, Morphine and Midazolan for pain and sedation given through separate IV lines, an oxygen saturation monitor and an indwelling catheter. Her resting heart rate was at 105 bpm with a mean arterial pressure of 136 and her saturations on 100% FiO2 were at 92%. On auscultation there was clear bronchial sounds in the posterior upper segments of the right and audible crackling throughout the upper lobes. The lower segments of the lungs had poor airway entry and therefore minimal breath sounds were heard. Her assigned nurse reported that she was de-saturating significantly overnight to extreme lows of 48% and required frequent suctioning via the ETT in an attempt to maintain clear lungs. By her 2^nd day in ICU, it was deemed that she was in single organ failure involving the lungs.

TASK

My task in this clinical situation was to gather all relevant information from the patient’s medical notes, nursing observations and relevant staff, as well as conduct a thorough assessment of the patient’s cardiorespiratory function to then present this to my supervisor and discuss optimal treatments.

ACTION

Firstly I gathered all relevant past medical history, the presenting complaint and her current admission journey as well as brief summary of her social background from her medical notes. I then consulted her nurse to gain any additional information about recent observations, information and objective measures noted. With all of this I deemed it necessary to do a screen of tone, reflexes and ROM to assess any potential neurological deficits or pre-morbid restrictions as well as cardiorespiratory assessments such as auscultation, breathing pattern analysis, effect of positioning on saturations and blood pressure as well as cough reflex.

I reported all of my findings to my supervisor with a clear analysis of impairments, a prioritized problem list and a plan of treatment.

RESULT

From the notes I was able to gather a fair amount of information, which made my patients background and pre-morbid status clear in my mind. I then had a good idea of a baseline as to compare my clinical findings with and identify a worsening progression.

The nursing staff acknowledged that I asked appropriate questions in a clear manner, enabling them to easily provide me with the answer I needed.

My supervisor also acknowledged that I had shown initiative to consult the nursing staff and the medical notes, prior to seeing the patient. She agreed with my reasoning behind my choices of assessment, analysis of the findings and my prioritized problem list with just a few additional notes to add. We then collaboratively came up with a plan for that day’s treatment to best address the identified problems that we could potentially impact on.

EVALUATION:

In this clinical situation, my greatest strength was my communication. My revision of specific cardiorespiratory terminology enabled me to express my findings, to my supervisor, in a succinct, informative and educated manner, while my broader understanding of the meanings allowed me to then translate this to nursing staff.

As this is my final placement, I am confident in communicating with various team members and find this a very useful means of gathering information when the correct question is asked. Being my only cardiorespiratory placement, I was initially unaware of the information required in a good patient handover and in this instance, my supervisor needed to ask a couple of additional questions to draw out information.

This situation particularly tested my ability to remain neutral and unattached. The patient was around my age and had been through such a hard life struggle, to now be in ICU with multiple attachments, organ failure and no family support, seemed so unjust and almost cruel. Something I will undoubtedly be exposed to often in ICU and will gradually come to terms with.

STRATEGIES

After being in this situation I will endeavour to plan my handover by writing down all elements I need to know about a patient to then handover to a fellow physio or team member. From this I hope to develop an individual method of doing this and hope it becomes more efficient.

Exposure to clinical situations offers experience and knowledge, which can only benefit me the next time I am presented with something similar.

INITIAL ENTRY - Fremantle Hospital Cardiorespiratory

Fingers crossed, last and final placement. Fremantle Hospital to signify the coming to an end.

At Fremantle hospital I will be undertaking my cardiorespiratory placement. This field of physiotherapy is one I enjoyed at university and found simple to grasp concepts and treatments, therefore I feel confident in my ability to perform well at this placement. As majority of my prior placements have incorporated some element of acute care cardiorespiratory or post surgical rehabilitation, this will hopefully help in my success on this placement.

Fremantle Hospital itself is an older facility, on a small location, though being the only public tertiary hospital south of the river has extremely high demands to meet. With the additional pressure of the four-hour rule, there is added stress on staff, which will undoubtedly be translated to students as well. This could play out two ways, being given a greater degree of independence to share the clinical case load or having a greater degree of supervision to ensure more efficient and quality care.

In terms of the nature of this placement; we have not yet been informed of the specific area of cardiorespiratory physiotherapy that we will be assigned to, whether it be cardiopulmonary rehabilitation, oncology or general surgical, there is great variety in the nature of each of these wards.

The structure however would be similar in that it is largely acute inpatient care where we will be designated patients to treat and assess throughout our placement. It will be my role to integrate into the team, assess and treat the patients I am designated, attend relevant meetings and professional development sessions and assist my supervisor and other staff members in any way possible to improve efficiency and quality of patient care. Meanwhile as a representative of Notre Dame Fremantle and a student looking to be employed as a physiotherapist in the near future, I will act professionally and acknowledge workplace policies and procedures as well as build good working relationships with the staff of Fremantle Hospital.

Prior to commencing this placement I have only a few concerns:

- The impact of the four-hour rule, specifically to cardiorespiratory patients. I found in previous placements, especially Neurology at Royal Perth, that the four-hour rule put added pressure on the emergency department to delegate patients to relevant wards quickly. This then meant that patients were placed wherever there was a free bed and often ended up in units not specialised for their care. Also as many patients have an element of cardiorespiratory, the variety of patient presentations may be overwhelming.

- Fremantle Hospital has featured in my past, and from previous experience, was not a satisfactory hospital with poor facilities, limited resources, mainly staff and a low standard of patient care. I am hoping that since this time, the standards have much improved and that my past experience doesn’t bias my opinion of the placement.

Overall I am excited to be on the home stretch and have my final placement in a field of physiotherapy that I feel confident with.

FINAL ENTRY - Royal Perth Hospital Stroke Unit - WSC

Looking back over this five week placement I feel I have come out stronger, and more confident. With such poor and negative expectations originally, it couldn’t have been worse then what I prepared for. With the main objective of gaining as much information that I could and passing so that I could continue the degree, I had little concern about how I was treated as a student. I have a strong exterior and can handle bullying without the need to retaliate, and in this situation this definitely played to my advantage. After being so confident from my last placement, this also helped a great deal in maintaining my interest in physiotherapy as a potential career.

My supervisor was originally hard to approach and seemed quite rigid in her ideas, though over the weeks, getting to know her I was able to adapt my style to work with hers, which worked to benefit us both. I was a bit disappointed that at the end of 5 weeks, the supervisor was still adamant on attending all assessment and treatment sessions with us students and was reluctant to allow us to do things independently. On a few occasions I attempted to show initiative and commence an assessment, or collect a patient on my own accord, though this did not fly well with my supervisor. So as a result we were constantly supervised, which was mildly frustrating. Overall though, she was definitely an expert in her field and had a lot of knowledge in the field of neuro physio, her explanations could occasionally be hard to interpret, though watching work with patients offered invaluable learning experiences that I will retain and employ in the future.

Royal Perth in general is a public hospital and like expected, is run like the other hospitals I have been to, though as it is a tertiary facility, the demands are just that one step higher. Staffing is an issue and patient’s presentations are that tiny bit harder so the workload can be an issue. Our stroke ward wasn’t particularly busy during our stay, so this wasn’t too evident in physiotherapy, and we often felt it pertinent to assist our fellow staff members with their duties.

My study prior to the placement had been useful, though more practical practice and knowledge wouldn’t have gone astray.

My concerns were evident, especially in the first week or two, though as the placement progressed I was able to figure out a way to adapt to my supervisors methods, which aided in my learning. The barriers to students was clearly evident, not so much from my supervisor, though other staff expressed this attitude, which originally dampened my confidence, though I soon came to realise that in a few months I would no longer be a student and that if they had such low expectations and value for students I would make it an aim to prove them wrong. This provided a drive and incentive to work hard and demonstrate my skills and knowledge to the best of my ability.

Experience is always a concern, though this is obviously something that I can’t impact on and will only take time.

Overall I found neuro physio highly interesting and valuable to translate skills to all areas of physiotherapy. My experience wasn’t the best, though was highly rewarding nonetheless. I feel the skills I have learnt will be integral in my career and would consider pursuing this area or physiotherapy in the future.

STARES 3

SITUATION

A 27 year old female was admitted to ward 8A under the neurology team for further investigation and treatment after presenting to the emergency department with signs and symptoms in her left lower limb including abnormal sensations, decreased active motor control, proximally greater than distally and increased tone of the classic extensor pattern. A CT scan of her brain and spine had been taken, as well as a lumbar spinal tap to determine possible causes for symptoms. All of these tests were negative.

On physio assessment it was found that she had an abnormal sensation pattern and experience in her left lower limb with a clearly defined areas. Normal awareness of sensation was graded 10/10 and using this as a reference, a specific sensory assessment was conducted to determine the most affected areas. According to the patient she had near normal awareness at her knee and on the plantar aspect of her foot with 8/10, though at her hip region and back of the thigh and calf she reported 2/10 awareness. Also noted was the description of as being “pins and needles” type sensation to all touch. In terms of active motor control there was decreased strength throughout the left lower limb in comparison to the right with impaired coordination. Tone wise, there was evident fatiguable clonus in gastroc and soleus on the left, as well as rigidity with passive movement into dorsi flexion. On standing, the left lower limb went into extension pattern with plantar flexion and inversion of the foot, adduction of the hip and hyperextension of the knee. Functionally she was independent with bed mobility and sitting balance, supervision for transfers and non ambulant on initial assessment. Her right lower limb, trunk and upper limbs were unaffected.

Subjectively, it was noted that the patient had catastrophising behaviours and was concerned about the lack of a diagnosis and prognosis.

The medical team, from lack of a clearer picture, and inability to find anything on clinical tests, diagnosed this patient with transverse myelitis, or inflammation of the spinal cord. For this she was started on steroid therapy to decrease the potential inflammation and hopefully alleviate some her symptoms.

TASK

In this situation it was my role to investigate this patients past medical history and relevant information from her medical file. From this I was too conduct a full neurological and mobility assessment to help develop an appropriate rehabilitation plan in the future.

ACTION

From reading the patient’s medical notes, it was unclear as to the cause of her symptoms and there was no indication of a diagnosis. To clarify this I met with her medical team to discuss her notes and their point of view of her situation before I went and had a look for myself. The medical team confirmed that all tests had so far been negative and they thought this could potentially be an acute attack of multiple sclerosis, though without evidence of plaques or prior episodes, this diagnosis could not be made. They felt that with a thorough physio assessment, the symptoms would be clearer and they could get a better understanding of her presentation.

I proceeded to conduct my assessment of the patient. On subjective questioning of the patient I gathered the relevant information about onset, history, current understanding and feelings and goals. This also helped me develop rapport with the patient as she was quite concerned and anxious about her pending diagnosis and sudden onset of muscle weakness with abnormal sensation. Being on a specialised neurology/stroke ward didn’t reassure her in the least, fearing she had experiences a stroke or had developed a brain disorder of some kind. I explained the process of assessment and how this would aid the medical team in the diagnosis, which would further help her rehabilitation, as we would understand how to manage her symptoms.

The assessment was carried out, with constant explanation and reassurance to the patient, as she was concerned about the impairments and their potential meanings. This included; muscle power, tone, detailed assessment of sensation, coordination, reflexes and functional capacity.

From my findings I had a feeling that this could potentially be an acute episode of multiple sclerosis; the patient reported that she had experienced clonus in her lower limb in the past and had tingling sensations in her upper limbs though didn’t think anything of it, the symptoms were unilateral and of quite an original nature and the symptoms seemed to have changed rapidly from onset to admission to the time of the assessment. This thought was not expressed to the patient and instead I discussed my findings with the medical team who agreed that they felt the same way, though as it was the first recorded episode, the diagnosis could not be made. Therefore they were planning to diagnose her with Transverse Myelitis. I received the okay to commence rehabilitation.

From this I then explained the diagnosis to the patient who had been informed by the medical team earlier that day, and also explained the effects of the steroid treatment she was to commence. We then collaboratively developed short term and long-term goals and a rehabilitation plan.

RESULTS

As a result of my assessment, the medical team was able to confirm the patient’s presentation and get a better understanding of her clinical picture. I was also able to develop an effective and targeted rehabilitation program with the patient to impact on her impairments.

Through effective communication I was able to develop a good relationship and rapport with the patient, which gave her confidence in my ability as her therapist and my future planning. My explanations also helped the patient understand her symptoms and treatment and she was better able to participate and grasp the concepts of her rehabilitation, making it easier to undertake treatment.

EVALUATION

With this particular patient, my biggest strength was communication. Coupled with this was compassion. Without being able to relate to this patient and truly portray empathy for her situation, I feel assessment and treatment would not have been so effective and the patient would have been swept away by her catastrophising beliefs. By giving her understanding, this gave her a sense of control, which gave me confidence in that she would be proactive in rehabilitation and motivated to participate at 110%.

Another strength was my thorough assessment and efficiency of conducting this. This also benefitted the patient as it built her confidence in me as her therapist. As it was my 5^th week and probably my 30^th full neuro assessment, I had developed a method that came naturally and easily.

A noted weakness was confidence in communicating with the medical team. In this particular situation I felt they handled the patients catastrophisation poorly after recommending she take part in a medical student study and be a case study they examined, which involved a room full of medical students trying to guess her diagnosis. After which the patient was clearly distraught by the suggestions made and spent an afternoon in tears. They also explained the findings of tests, eventual diagnosis and steroid treatment. I expressed this to my supervisor who said it is often left to the allied health team to translate medical information to the patients as they are often pushed for time.

STRATEGIES

Some strategies that were / could be useful in similar situations are:

- Building rapport with your patients through understanding and empathising. Also having good prior knowledge of their situation and researching elements of their history prior to seeing them gives an extra head start before seeing the patient.

- Planning assessment before going in, though avoiding having expectations as this could bias your interpretation of results.

- Utilising the knowledge of the whole multidisciplinary team and having confidence in own background to backup and present your argument in any open discussion.

STARES 2

SITUATION

A 37year old female was diagnosed with multiple sclerosis at the age of 27years old. This patient had suffered frequent relapses in multiple sclerosis with a variety of presentations, including complete blindness, paralysis and incontinence. She presented to Royal Perth hospital under the recommendation of her neurologist when her latest episode failed to relinquish and seemed to be progressing. Early in May she reported waking up with loss of strength in her right lower limb. This further progressed in the week to a radiating “electric shock” sensation to touch, throughout the left side, below the T4 dermatome. On admission, an initial mobility screen and assessment was completed. From the subjective it was found that she had struggled with multiple sclerosis for 10 years. In this time she had had numerous relapses with some residual deficits including impaired sensation in her upper limbs. As well as this struggle against the unknown, on her journey she had discovered that she is immune-deficient and has severe life threatening reactions to most multiple sclerosis control medication. Her lifestyle choices like smoking and unhealthy diet, regular hospital admissions, steroid treatment and past wheelchair dependency for periods at a time, she had become obese. With the additional weight and regular steroid treatment, rehabilitation became very difficult and limited severely by fatigue. She had also had bad experiences with rehabilitation in the past, with little input and persistence, she had been deemed wheelchair dependent by her therapists. She then taught herself to walk independently at home, which resulted in shattered knee-caps and hip injury from repeated falls. Coming to Royal Perth she was astounded at the amount and quality of input she was receiving. On admission she was ambulating with a family walking stick and one assist for short distances, otherwise she used her wheel chair. On ambulation she had a poor pattern with excessive compensation. Rather than using the walking stick as an effective aid, it was used like a tripod to extend her base of support. From this we incorporated gait re-training as a fundamental component of her rehab. Upon discharge she was referred to Shenton Park campus for further inpatient rehabilitation.

TASK

For this patient, my task was to conduct a thorough subjective and objective examination to ascertain the full clinical picture. From this I was to develop a treatment plan with options to modify as her clinical presentation was changing slightly day by day. After 2 weeks of rehabilitation I had the task of planning her discharge and referring her to Shenton Park Campus.

ACTION

On commencement of the examination, I discovered through the subjective that she had a poor history with her therapists. I therefore took a sensitive approach to her history and struggle with her condition and thoroughly explained the process of examination and rehabilitation offered at Royal Perth. After gathering a clear clinical picture of this patient, with extensive questioning I conducted a brief neuro screen, assessing tone, sensation, proprioception, strength and coordination. I then began a mobility screen, starting with bed mobility, transfers and finally ambulation. I found she was independent with bed mobility and transfers, though required excessive effort to complete the tasks. On ambulation, I had to educate her on technique and aid use. From observation of her pattern I deemed it more appropriate for her to use a wheeled zimmer frame to provide the additional support and balance that she required to demonstrate a more efficient gait pattern. This mobility screen fatigued the patient. I discussed fatigue with the patient and educated her on knowing her limitations. We then organised an appropriate time to begin treatment the following day, at a time when she felt she had the most energy.

I devised a treatment plan to address her fear of the forward space, lack of trunkal dissociation and control, standing balance and foot awareness. With this treatment plan was a few other options or avenues we could try if the first idea wasn’t optimal. We commenced treatment the following morning, ensuring all treatments were related back to functional gains to provide motivation for participation. The patient worked well and at the onset of fatigue I took the patient back to her room. I prescribed her with an exercise program to continue in her room throughout the day when she was feeling up to it.

We continued rehabilitation throughout her stay, progressing her exercises to continually challenge her. I developed good rapport with the patient and we worked well together.

The multidisciplinary team discussed her discharge options and it was globally decided that further rehabilitation at Shenton Park was optimal. I discussed this with the patient and she was eager to begin. I completed her discharge summary and contacted Shenton Park to relay the relevant information.

RESULT

As a result of my assessment, I was able to coordinate an effective treatment plan and carry this out with my patient with success. With constant re-assessment and regular input we were able to progress her rehabilitation throughout her stay and improve her independence with transfers and her effectiveness in gait. We developed a good rapport and understanding and I feel this helped with her rehabilitation and acceptance of therapy input. She participated in her therapy sessions and from what I gathered, carried out her exercise program, this optimised her chance of recovery. My supervisor was satisfied with my performance with this patient and was confident with my approach, therefore allowed me to conduct majority of sessions independently. She was also pleased with my discharge planning and supported me in the decision to refer this patient to Shenton Park for further input.

EVALUATION

In this clinical situation I feel I communicated well and my ability to build rapport and understanding with this patient was good. With prior experience and knowledge of multiple sclerosis, this gave me an advantage in understanding the patients struggle and I was able to adequately relate to her difficulties.

My treatment plans were appropriate in their level and difficulty. They were challenging yet achievable, therefore the patient was satisfied with their performance and motivated to continue with therapy.

Elements I could improve on would be my questioning throughout the subjective as I feel there were crucial elements I didn’t thoroughly explore and gain a clear enough picture of. Throughout our treatment sessions, I was able to ascertain this information.

Also my confidence in the multidisciplinary team meetings could do with improvement. During the meeting I was asked for my input on the patients status in physiotherapy. I gave an overview of her mobility, her key issues that we were working on, and what we were doing specifically in treatment sessions. My supervisor then provided the additional information that I failed to mention of rehab potential and our plan to recommend Shenton Park.

STRATEGIES

Having multiple treatment strategies worked to my advantage, as I was able to modify my treatment sessions depending on the patients level of symptoms and alertness. An independent exercise program for the patient to do independently is also a strategy I will employ in the future as this gave my patient a degree of control over their rehabilitation and gains and I feel also improved the gains we made as she was practising what we did in our sessions throughout the day.

Breaking the subjective down into components that are easier to comprehend and handle would improve my efficiency in questioning.

Lastly preparing fundamental information that needs to be relayed in the team meeting for each of my patients would be handy to improve my confidence in these situations.

STARES 1

SITUATION:

A patient was transferred from the ED department to the neurology ward for further treatment. She had presented to the ED department complaining of a severe headache behind her right eye and a sense of vagueness and confusion. This was later diagnosed on CT scan as a haemorrhagic stroke in her right frontal lobe. On initial admission, the patient was medically unstable, therefore only the necessary mobility screen could be carried out on day one. Initially she required two people to assist transfers and could only step stand transfer over the right side. Her sitting balance was poor, standing balance almost non-existent and she was not ambulating. By day two, there was lingering drowsiness, though she was now medically stable and her headache had eased. A neuro assessment was commenced and it was found that she had a low affect, significant rigidity throughout her right side, lower and upper limb, mild problem with initiation of movement, reduced ROM in her right shoulder secondary to a rotator cuff repair a few months prior, poor postural control and poor pelvic, lower limb and trunk dissociation. On the Gowland assessment she scored level 6 on most parts. Day three her presentation had changed again. She was now requiring one assist to transfer and ambulating in physiotherapy only with maximal assist of one.

TASK

My task in this situation was to conduct the initial mobility screen of this patient, complete a full initial neuro assessment and plan and carry out daily physiotherapy sessions.

ACTION

After I had conducted the initial assessment and developed a problem list for this patient, I developed some ideas for treatment and presented this to my supervisor. We were in disagreement in the approach to this patient as I was adopting a more functional approach, where as my supervisor wanted to address the impairments specifically. I carried out a fairly standard treatment session addressing impairments, which incorporated bridging and trunk control activities in supine, encouraging glute activation. I then finished this session with a facilitated walk. As she had a haemorrhagic stroke, her presentation was highly variable and by day four, Friday, she was requiring moderate assist of one for transfers and ambulation. My treatment focus then turned to addressing her pelvic control in standing and her confidence towards the forward space to bring her centre of mass in front of her base of support, making sit to stand transfers and walking easier.

RESULTS

My supervisor didn’t encourage walking this patient, though after seeing me walk her in my treatment session with the tutor, she identified that with appropriate facilitation, her gait pattern was near normal. I was able to show my supervisor that my observation of this patient’s ability was good and the treatments I had chosen were suitable. Focusing treatment on a functional task involved the patient more as she understood the relevance of the activity. This also boosted her confidence in recovery and physiotherapy.

EVALUATION

It has been difficult to build rapport with my supervisor on this placement as I feel a functional approach in some cases is more appropriate than addressing impairments specifically. When the functional ability of a patient is high, I feel that the impairments can be addressed through fine-tuning of the functional tasks rather than taking the patient to a non-specific task that addresses the impairment in isolation. In this particular situation I had this difficulty. Though I was able to see this patient with my tutor who agreed with my decision to walk this patient, which was fairly successful. Something I could perhaps improve on is my confidence in my ideas and ability to translate this to my supervisor.

Also my neuro assessment wasn’t systematic and it was obvious that this was my first experience with this. This is something I will need to work on and practice to improve my efficiency in assessment.

My communication to my patient was appropriate and effective. I found it easy to develop rapport and engage the patient in treatment. Another element I need to work on is facilitation. This again comes with experience.

STRATEGIES

- Relate all treatments to tasks that the patient find relevant to their goals. This helps with engagement of the patient in treatment sessions

- Confidence in observations and treatment ideas to relay this to my supervisor.

- Planning assessment in order of position eg. Supine tests, sitting tests, standing etc. This improves the flow and efficiency of the assessment process.

Initial Entry - Royal Perth WSC Stroke unit

In anticipation of my third clinical placement at Royal Perth Hospital I have begun preparation for a highly demanding five weeks. From my peers I have heard that generally placements at Royal Perth are challenging, in that expectations of knowledge and ability are of the highest standard and that staff tend to derogate students. Combined with this feedback, is a pre-warning that my potential supervisor can appear to be “a bully.” With this in mind I am anxious, again. The sense of unknown is un-nerving and with the feedback I have received about this placement, it has not been comforting. As I am coming into this placement on such a high from my last placement, I feel this could work to my advantage as this has built my confidence.

Royal Perth is a hospital in the public sector. I am assuming this will be run like most hospitals in that there will be a high focus on the multi-disciplinary team and a more or less blanket referral of patients to the wards physiotherapist. As I have had prior placements on wards in hospitals, I am confident that I will know the structure and procedures in how the ward operates. I have also had practice in writing inpatient notes etc, so this should alleviate some initial pressure.

For this placement specifically, I have revised my neuro, in particular stroke symptoms and presentations as well as neuro assessments. I am hoping this is sufficient to get me through the first couple if days, until I get an idea of specific knowledge that is required from me.

I feel my role in this placement will be to support the existing structure, participate in the multidisciplinary treatment of patients and conduct myself professionally as a potential future physiotherapist.

Prior to commencing this placement I have the following concerns:

- That I will not be able to establish a positive learning relationship with my supervisor.

- There could potentially be barriers in terms of negative attitudes towards students, impairing my ability to gain a lot from the placement through interaction with colleagues.

- With little experience with stroke patients, I may appear inexperienced and uncoordinated in this area.

Overall I am most nervous about this placement, as it is a field I feel I have the littlest experience with and from the feedback I have received I will have barriers to overcome. I am also anxious that if I feel overly intimidated I may be less inclined to take advantage of learning opportunities, as I will be afraid to ask. With the support of the Notre Dame staff, that I can rely on if things become too overwhelming, hopefully I will be able to overcome any unnecessary anxiety and awkward situations I may fond myself in.