How I see it … timely reminders

Today I was reminded of a few valuable lessons.

After some time away from my job recovering from surgery, new students returned today, which meant being back on campus and in a lecture theatre in front of more than 200 students.

For me, being in front of a class, explaining, unpacking, discussing and storytelling to make a point that may influence future practice is where I feel most at home. If people had asked me 10 years ago if I was happy public speaking, I most likely would have answered no. However, now, it is second nature and a place where I can make a difference by encouraging, inspiring, and motivating our future nurses to influence healthcare for the better.

I went to work today subconsciously expecting things to be the same as they had for the last 10 years. That I could walk in with ease and the confidence that I usually portray. On the surface, this is most likely what the students saw, but for me, it was a time that included uncertainty, vulnerability and adapting to the new normal.

I have recently had complex eye surgery on my sighted eye. This has meant variable, distorted and blurred vision along with side effects of medications (including nausea, headache, blurred vision and high blood pressure). Along with this, my glasses prescription has changed, which has worsened the blurred vision and distortions. It will continue to change for another two months, and I can not afford to get new glasses now and then again in two months. Although I knew that my vision would change after surgery, and I had begun making adaptations, I had not anticipated the subconscious physical and emotional impacts.

Usually, preparing and setting up for a lecture is a breeze. This time, I managed to anticipate some adaptations before arriving; however, I soon learned that some were different or more challenging than I expected. One example was using the lecture theatre computer and touchpad that controls lights, microphones, recording and audio. I had asked a colleague to help; however, as he helped, I noticed I had a specific way that I liked things set up that others may not find intuitive. My usual method meant I did not forget anything. But today deviating meant that I omitted some things that make life more comfortable for students, such as dimming the lecture theatre lights to see the slides better. While this may not seem like a big issue to many, it made me feel a little unsettled.

Before arriving, I had decided to let the students know that I had recently had surgery and could not see as well as I usually did. I anticipated that this would be necessary when students outside of my field of view or were blurred raised their hands to ask questions. As a solution, I planned to stop more frequently, check students’ understanding, and ask students to call out when they had a question telling me their name as they asked the question. This approach meant showing my own vulnerability to students. I usually do not have a problem showing students vulnerability while teaching. For example, letting students know when I do not know the answer to a question they ask. However, sharing personal information or admitting my limitations to over 200 people made me feel more vulnerable than usual and instantly doubt my decision to share the information and ability.

The social context of education was highlighted as students quickly reverted to putting up their hand and waiting patiently to ask questions. While I noticed some students, I did not see others, which left me questioning whether students felt that all of their needs were met during that session. As a solution, I had already suggested students post questions unanswered to the discussion forum. To date (15 hours later), no students have posted questions, leading me to believe that students are OK. This situation highlighted how I rely on visual cues as feedback from students in group teaching sessions. In future, I plan to consciously make other avenues for cues more overt by encouraging students to use more verbal prompts.

While the lecture and discussion were delivered and received with ease, maintaining the learning environment raised challenges. The timing was perfect, and as usual, some students approached to ask questions at the end of the session. With my colleague who helped with the setup now gone, logging out of the computer became a challenge. I could not read the small menu of the lecture theatre computer, and the next class were filing in with lecturers waiting to take over the room. I ended up letting a student who was waiting to ask a question log out of the computer for me rather than initiating a discussion about this with the staff waiting to start the next class. While logging out was necessary. It reversed the traditional teacher and student role, where the student asks the teacher for assistance.

I walked away from the class feeling that I had not performed as well I “should” or “usually” do and wondered how this might affect students. Several students approached after class, thanking me for easing them into the paper, which reduced their anxiety about the course while introducing some new concepts. This reminded me that we all come into a situation with our own fears, students around the unknown course content or expectations. Whereas I feared making mistakes in content delivery and students losing faith in me because I could not see them well enough to realize that they had questions. Interestingly, it wasn’t either of these things that I struggled with instead of the environmental tasks.

The situation described above has predominantly reminded me that being honest about my challenges/showing vulnerability itself, be a teaching tool.

How I see it … Post PhD Exhaustion

I handed my PhD in on Tuesday this week and I must admit it is a relief it is gone in. However, what I didn’t anticipate was the sheer exhaustion after having finishing it.

As expected, the PhD has been replaced by an increased workload. But, what I didn’t anticipate was the sheer exhaustion after finishing and the impact this would have on my own functioning. I had been doing 60+ hour weeks to complete and found that while I was doing this, I didn’t notice the physical and emotional signs of fatigue as readily. However, since handing in, I have realised just how fatigued I actually am.

Fatigue is not new to me. As someone with a vision impairment, I generally read very slowly and favour discussion or audiobooks. To compensate for reading taking me longer than those around me, when I need to read and am under time pressure, I often subconsciously read by the shape of the word rather than larger text, but this can cause errors. The more visually fatigued I get, the more I revert to reading by the shape of the word. It is a chicken and egg situation as I make more errors when reading by shape, or large print reduces errors but is much slower, and I work longer. Either way, it takes more time and visual energy.

Just over a year ago (2 years into my PhD), I realised that “visual fatigue” was an actual issue. I found myself subconsciously needing to take a break at 0930, 1300 and 1530 ish every day whereas before I could just keep working through these. When I analysed the situation, what I was doing was subconsciously reducing visual activities, such as getting away from the light, screen, office and moving objects. I was finding that when I was beginning to get tired ordinary tasks became a problem, such as the room lights would be too bright, I would walk into things and people (with an already reduced visual field) and anything that took visual processing became a considerable effort.

My strategy until this time had been pushing through these things and keep on going, but now the problem was that the effectiveness of this solution was inadequate. I also found that my peers didn’t understand the extra need for time or the extra fatigue with visual processing for someone who has low vision. I didn’t really know any different so would explain I was tired, often the response I got was “well we are all tired” or “PhD is a right of passage, it is hard”. So to be less of a burden on those around, I gave up trying to explain, worked harder, longer and just kept on going.

The interesting part of this story is the impact of the PhD related fatigue. Usually fatigue is manageable, but post handing in my PhD, I am actually noticing all of the things which relate to visual fatigue more, whether they are actually more of a problem or whether I am noticing them more is a different issue. But, proofreading is harder, lights brighter, walking home in the dark is more of a challenge and even distressing, even using my computer (which I usually enjoy) is causing more than usual problems. What this has reminded me is that I need to remember to know myself, to notice when things become difficult and actively work to reduce the issues. Literature suggests people with low do take longer to process and fatigue more quickly because of needing to process what they see differently. Yet, for me, who relies on evidence based solutions, this is hard as it means asking for more time for things.

The dilemma here is I see those around me working hard, I don’t want to be seen as different, but, If I just keep going, I will start to make mistakes and become more fatigued. Yet, I want to support those around me and don’t want to be seen as a person who doesn’t do her share. My natural instinct in this situation is just to keep on going, but, in some respects this is not the right solution, nor is it sustainable.

Today, I couldn’t keep on going and had to stop visual processing and go and rest. Noticing this is a positive step for me, yet in the background, I feel guilt as I know there is more work waiting and others relying on me to get things done.

Back to the good part my PhD is submitted!

How I see it … getting around in the UK and Hamburg

For those of you who are new to my blog, I am a nurse and academic who happens to have a vision impairment. In the last year or so my night vision has decreased and susceptibility to glare has increased. To learn more about my vision, please see my previous blog entries. I have recently started using a white cane to get around mainly when it is dark, or the glare is excessive.

This blog post primarily focuses on moving around London using public transport to get to the conferences that I have been attending along with visiting friends and family. There is a lot to cover, so I have concentrated on spatial awareness, travelling on the London tube, the pedestrian environment and crossing signals.

So far I have participated in an education conference in Bloomsbury, London for three days, visited friends in Hamburg and Oldenburg in Germany and am currently staying with family in the south of England until returning to London for a Digital Health conference next week.

Spatial awareness …

One thing that has stood out while moving around in the UK and Germany is that people appear to be more spatially aware than those in Auckland. What I mean by this statement is that so far fewer people seen to walk around staring at their cellphone or feet and more people seem to notice what is happening around them. While this is a generalisation, and there are always exceptions to the rule, I feel safer moving around in crowded areas because more people notice what is around them.

One of the challenges I have is in crowded areas where people moving around me affect my ability to judge distance, and any movement distorts my vision; this means that I tend to limit moving around and feel nauseous when others move.

The other surprise was the number of push bikes in Oldenburg; however, these travel on the road or bike lane on the footpath and both pedestrians and riders show far more respect for others sharing the space than I have encountered in Auckland. The part of navigating around Germany that was the most challenging was re-learning traffic patterns and remembering traffic approaches from the opposite side of the road. A tip for vision impaired travellers is that there are no buttons on to press at the crossing, but you need to cover the whole front of the box with your hand, and it detects this. Hidden on the bottom is a plastic indentation which moves when the light is green.

On reflection moving around as a pedestrian in both London and Germany has been less stressful than I expected. I suspect this was directly related to the spatial awareness displayed by others and the distinct lack of electric scooters on footpaths. While I have been known to ride an electric, I did not realise how much stress sharing a path with unpredictable and fast electric scooter riders in Auckland had caused me until I was in a place where they did not exist.

Travelling on the London Tube …

Navigating the tube has been an “interesting experience” the most significant difference from Auckland is the sheer volume of people who try to fit onto the one train is somewhat overwhelming. Often I have found that I am standing holding on to a rail with people crushed against me on all sides. As someone from a country where there is less crowding on public transport, I found this quite confronting. In comparison, the trains in Hamburg were very well scheduled and timed, and this meant that I always got out of one train carriage, walked about ten paces across the platform and got straight on to the other train which meant that both platforms and trains seemed less crowded.

However, in saying this, in the UK, even though the transport system is crowded, many staff members are there to assist in navigating the system and are very quick to offer assistance. For example, at Victoria station, I stood for around 30 seconds looking at a sign before I was approached by station staff asking if they could assist, he then offered to walk me to the platform I needed.

Similarly, each time that I have entered a tube station with my white cane, a staff member has approached and asked if they can help – which is fantastic. So far the assistance I have accepted has been in the form of asking the way to a particular platform and I have been given very clear directions and if I have declined further assistance staff have accepted this without question. What has stood out is that the workers in London and on the Southern UK train network never seem to make assumptions about the assistance that I need but asked if and how that they can help.

In contrast, interacting with members of the public travelling has been variable. I have had some very positive interactions and some very poor interactions. For example, in a packed tube train where I was standing surrounded by people and unable to move in any direction, the tube stopped at a station, and several people got off of the train. A woman grabbed both of my arms and pushed me into a seat saying “sit down”. A seat is excellent, but, I was somewhat overwhelmed by someone deciding that they could by physically moving me without asking is not pleasant and is also making assumptions about my needs. This treatment put me in a vulnerable position, where I felt very uncomfortable.

The Pedestrian Environment …

After travelling in New Zealand, Sydney, Brisbane and Melbourne, I was surprised that the distance between the platform and train was so variable in both height and length. Similarly, the curbs and stairs are also variable. While many people could argue that this is a part of history and charm of London, this has meant is that I have had to rely on my white cane to determine distance far more than I would at home. An advantage of this is ensuring safe travel, but as a part-time cane user, it has been an emotional step for me to increase the cane use.

wlo-bl-nbplat

Photo from: https://www.squarewheels.org.uk/rly/LUgenPhots/WLO-BL-NBplat.jpg

Some tips that may assist vision impaired travellers:

UK General:

  • Accessibility is well legislated, conferences etc. offer large print and accessible materials as a standard.
  • Audio described performances at the theatre are common and often no extra charge.
  • Attractions will often offer different and more extensive tours to those with a disability.

UK Transport and Travel:

  • Obvious one traffic drives on the left.
  • Expect more crowds.
  • Traffic signals have tactical markers under the box in the form of a cone that spins when it is safe to cross.
  • Train platforms aver variable in distance and height to and from the train.
  • Stairs in the underground are variable in markings (can be absent), shape, size and surface.  They can also be odd shaped such as curved with unexpected pedestrian tunnels crossing in older parts of the network.  London Transport offer guidance on how to avoid stairs they also offer accessible journey planning advice including planning trips without stairs.
  • Some platforms are curved and not straight.
  • Cobblestones are problematic, consider a rollerball tip for your long cane.  If you did not bring one you can order one online or buy one onsite at the RNIB in London.
  • Tube Maps are tiny to read.  You can download a PDF or order Large Print and other formats.  An audio guide to the london underground is also available.
  • You can order a badge saying “please offer me a seat” although I did not do this and can not comment on the usefulness.
  • Concessions may be available.

Germany (Hamburg and Oldenburg):

  • Obvious one is that traffic drives is on the right.
  • No buttons on the crossing boxes, apparently you cover your the front of the box with your hand to activate the crossing if this is required (some crossings are automatic) and tactile feedback is an indentation on the underside of the box.  
  • Cobblestones are problematic, consider a rollerball tip for your long cane.  If you did not bring one you can order one online or buy one onsite at the RNIB in London.
  • People seem less likely to offer assistance with less staff at stations in Hamburg.

How I see it … Evidence versus Protocol

Two things are on my mind today, the first relates to immersion in my PhD topic and the second relates to getting around in the dark.

I have been so focused recently on completing my PhD that I hadn’t stopped to think about the broader context. When I first started my PhD journey in 2016 I believed that my ideas and research would change the world – well resuscitation practices in New Zealand to be more precise.

The expectation of changing practice has motivated me to continue working on my research over the last four years. What I mean is I felt that this was the end goal and was achievable.

With around 2000 words left to write (one more topic in the discussion, the limitations, future research and conclusion) my motivation has begun to wane and to change the world doesn’t seem as realistic as it did previously. I am left wondering how to translate the results of my PhD into action when publication alone is not enough.

In 2015 I published work that proved that current practice was not accurate and in 2016 provided a solution. Despite being published in a Journal that reaches the specific population of clinicians required the previous research and proposed changes have not been further validated or found their way into practice. While testing and statistics show that my PhD work improves accuracy and reliability is society ready for change?

I now doubt whether my PhD research is worthy of continuation because my previous research does not seem to have made a difference other than to inform and provide a starting point for my PhD.

On reflection, this makes me question the power of published evidence to instigate change in practice. The previous change in method that I suggested was motivated by statistics, which showed a 35% increase in accuracy with a small change in the process. Surely this is evidence?

As a clinician, I am conditioned to use evidence-based practice, and my registering body calls for us to utilise research to inform practice. In this case, even though the evidence is out there the uptake is poor and change is slow. This causes a dilemma in such a protocol based profession, follow the rules or follow the evidence. I do not believe either of these should be mutually exclusive yet this is what I see in practice and is evident in the user testing portion in my PhD.

When I tried to discuss this with one colleague, they suggested that I am on this journey to gain a PhD and don’t need to change practice. However, I feel that without changing practice what is the point of doing a PhD?

Another wise colleague suggested that all students come to a point in their PhD journey where they doubt the work they have done as they only see the limitations and not the positive outcome. This is a good point, but, as a researcher, I am feeling a little demoralised with the inability of my prior research to change clinical practice it seems logical that the research extending in my PhD will also not instigate a change.

I will save the post about getting around in the dark for my next blog entry as this one has become rather long.