NR 575 Week 8 Practicum Closing Memo Example

Memorandum

To: Course faculty, Acute Care Practicum II

From: AGACNP student

Date: Week 8, Friday

Re: Closing account of the practicum aims, what two rotations did not supply and where the file reads inconsistently

Disposition of the Aims

The aims below follow the order of my week 2 revision memo. Each is marked closed, superseded or still open, with a line of support.

Aim 1, plan offered first on intensive care rounds. Closed. Seven of nine second-term forms marked "plan offered independently"; the appraisal in week 5 also recorded this aim as closed, and nothing since contradicts it.

Aim 2, daily ventilator decisions for three intubated patients over two consecutive days each. Closed. The third patient, with aspiration pneumonia, was managed for two days in week 6, and the notes were cosigned with no changes. The week 5 appraisal recorded this aim as partly closed with two patients; the third patient accounts for the change.

Aim 4, two radial arterial lines under ultrasound. Still open. One placed in week 4; a second attempt in week 7 was stopped after two passes by the supervising intensivist, and the line was placed by the intensivist. I have recorded it as an attempt, not a placement.

Aim 5, two family meetings with a pause after the hardest information. Closed, with a qualification. The second meeting took place in week 7. My preceptor's written comment says that I paused after explaining that the patient would not survive the admission, and that I then asked each family member in turn what they were thinking, including the one who was angry. The qualification is that the first meeting's comment recorded the change slipping once, so the aim closed on the second attempt rather than the first.

What Two Rotations Never Supplied

Several things I expected to see across two placements did not occur. I never managed a patient on vasopressors from the first dose; every such patient arrived on them. I never made a decision about withdrawing life-sustaining treatment, though I attended two meetings in which others did. I never placed a central line, because neither unit allowed students to, and I did not write an aim for it. And I never made a decision at night without a supervisor reachable within a minute; all my practicum hours were days. These are not failures of either placement; they are the edges of what two day-shift rotations supply. In one national survey, about half of new nurse practitioners felt only somewhat or minimally prepared at graduation (Hart & Macnee, 2007), and naming these edges is how I intend to avoid discovering them on the job.

Where the File Reads Inconsistently

One inconsistency remains. My week 4 evidence map recorded procedures as partly met on the basis of two punctures and one arterial line. My week 7 portfolio reconciled the first-term and second-term records and called that position consistent. This memo now records aim 4 as still open because the second line was not placed. The version that stands is this memo's: aim 4 is open, the procedural competency remains partly met, and the map and portfolio are accurate as of their dates but not as of today.

A second, smaller point: the week 5 appraisal listed three unsupervised gaps. One of them, comfort care planned without palliative specialists in the room, has partly closed since: I wrote a comfort-focused care plan for a patient in week 7, which my preceptor reviewed and changed in one respect, the timing of an as-needed dose. The other two remain open and appear in my transition plan.

Items Carried Forward

Arterial line placement under supervision, one more, in my first position or a fellowship. A meeting where relatives disagree, with a senior colleague present, within three months of starting work. Managing a rising plateau pressure overnight, through two simulation scenarios already scheduled for next month and on the job with a colleague available. These match the blocks in my transition plan, with dates and the people I need.

Requests to Faculty

I ask faculty to note aim 4 as open in my file rather than closed by the earlier map, and to attach this memo to the evidence map and portfolio so that a later reader sees the current state. I also ask whether the program can confirm the two simulation scenarios scheduled for next month, which my transition plan depends on for its first item. Neither request changes a grade; both keep the file consistent with what happened during the term, which is what a later reader of the file will need.

Sources Relevant to This Account

Self-assessment without documentation is often inaccurate (Davis et al., 2006), which is why every disposition above names a form, a note or a written comment. Communication practices for serious illness emphasize responding to emotion before decisions (Bernacki & Block, 2014), which is the standard aim 5 was measured against.

References

Bernacki, R. E., & Block, S. D. (2014). Communication about serious illness care goals: A review and synthesis of best practices. JAMA Internal Medicine, 174(12), 1994-2003. https://doi.org/10.1001/jamainternmed.2014.5271

Davis, D. A., Mazmanian, P. E., Fordis, M., Van Harrison, R., Thorpe, K. E., & Perrier, L. (2006). Accuracy of physician self-assessment compared with observed measures of competence: A systematic review. JAMA, 296(9), 1094-1102. https://doi.org/10.1001/jama.296.9.1094

Hart, A. M., & Macnee, C. L. (2007). How well are nurse practitioners prepared for practice: Results of a 2004 questionnaire study. Journal of the American Academy of Nurse Practitioners, 19(1), 35-42. https://doi.org/10.1111/j.1745-7599.2006.00191.x