A guest in their home

25th September 2015

Back in my home training hospital I started worked through the final leg of my three year training in 1986. Unlike many of today’s nursing students, we each had the same number of placements in the same types of areas (Theatres, ITU, surgery, paediatrics, medicine, gynaecology, accident and emergency...). It is very different for the modern day student; although they must complete the requisite number of practice hours, where that experience might take place can vary tremendously. This is primarily due to the stiff competition between universities trying to get their students into limited numbers of placement areas, or rather limited placement areas that have the necessary staff to ensure a viable and safe learning environment for students. Of course, the location does make a difference too. In the south-east, despite the many densely populated areas, there are fewer hospitals than in the past and far more primary care (community) services. This is no surprise given this is where successive Governments have focused their energies in providing care as population numbers have risen and longevity increased. Now there are simply too many people with long term illnesses (conditions) to have them all in hospital. So today’s nursing student can work in a wide variety of clinical areas, any number of which may be in primary care with school nurses, health visitors, sexual health nurses, practice nurses, district nurses and so on. However, despite the fact that a community placement emphasises the complex and skillful preventative and long-term aspects of nursing care, the variation in placement experience can be a source of frustration for student nurses with placements in acute settings often being highly prized.

How things have changed. In my training, the majority of our clinical experience was gained in our home hospital with just one relatively short community placement with the district nurse. For mine, I worked with in the towns of Radlett and Park Street accompanying the District Nursing Sister on her daily rounds and helping with insulin injections, washes, suture removal and dressings. All good experience and much more hands on than it is now (since the division of nursing care and social care, when washing people became nobody’s responsibility). Once we visited an elderly man with bilateral venous leg ulcers. His dressings need removal, his legs cleaning and new bandages applying. The house was dirty, his legs smelt terrible and there were several cats adding there hairs to the general mess and disorder. However, 'on the district' you were always reminded that you were a guest in somebody’s home and could be asked to leave any time. So you worked with the patient in their bedroom, their kitchen or living-room and that might well include working around the dried up pet food, the over-flowing bins and the animal faeces. In the area we were covering, we served a mix of people from the very rich (far more of these) to the less privileged. It was quite an eye-opener for me. Coming from an average 'three bed semi' family, it was my first ever glimpse into how people beyond my own circle of family and friends lived.

Community nursing is quite a different power differential to the one that patients experience in hospital, where the minute they put their pyjamas on, they surrender their (despite our best efforts) dignity and privacy and hand over control to the so-called authority of the nursing staff. It is important that students have a chance to experience these different settings and to recognise the underlying factors that play into how nursing care is provided and received in each of them.

On losing a loved one

In a temporary departure from blogging about my experiences as a student nurse, I’d like to pause for a moment or two to reflect on my experiences as a visitor to the NHS. Last week’s (very welcome) announcement that car parking fees at NHS Hospitals would be removed or minimised for those visiting long term in-patients or the critically ill, reminded me of the time 12 years ago when I became a visitor to the NHS rather than an employee of it.

My mother was 68, and an enthusiastic cook and traveller. She chaired the local Town Women’s Guild, swam regularly and loved gardening. She had a wide circle of long-standing friends and a beautifully kept home. She came to grand-parenting late (my fault) but adored her two grand-children and made life wonderfully fun and interesting for both of them. She lived not far from me with her (second) husband of many years and together they made a very happy and active couple. I don’t remember her ever being ill and aside from when she had my sister, and I don’t think she had ever been in hospital in her life.

One Thursday evening I called Mum for a chat and she said she thought she had strained her back gardening. She was had taken some pain killers and was having a lie down on the sofa to wait for them to work. We had a chat and I thought nothing more of it. Two days later, on Saturday afternoon, I called her to see how she was feeling. This time she sounded a bit drowsy, her speech a little slow and distant. She said the GP had been out for her back pain and prescribed Diazepam to relax the muscle spasm. No surprise then that there was transatlantic style 5 second delay each time I said something. It was so out of character for her that I said I’d pop over and see her but typically she was insistent that I didn’t bother, she would be fine she said. A bit troubled by our conversation, I jumped in the car with the children and went to see for myself. She was lying down, a little drowsy but cheerful enough. We didn’t stay long so as to not tire her and my step-father said he would call if there was any need, so we left again. On Sunday I called and he said she felt a little better after a reasonable night’s sleep. Back pain is awful. It is tiring and persistent and affects everything you do. There was little I could do to help beyond what my step-father was already doing so I stayed put at home.

On Monday afternoon, I was in the garden with two friends. The sun was shining and the children were playing with watering cans and buckets. The phone call from my step-father to say he was in the local A&E with my mum was totally out of the blue and I had to do a quick mental switch from unconcerned, mother of two to very concerned daughter of one.

I called my sister to let her know (although I knew no details of what had happened) and drove to the hospital as quickly as I dared. On arrival, my step-father, Rob was outside the A&E waiting. He said that Mum had got worse during the night and that he had called the GP in the morning. The GP had come out to the house again (a different one this time) and couldn’t work out why Mum was in so much pain. Eventually, he had decided to call an ambulance. My step-father an articulate and sensible man, had no real information to add. To this day I don’t really know what happened between the onset of back pain on the Thursday and the admission to A&E. The trouble with being one removed from being the next of kin is that nobody tells you anything and nor are they obliged to. Something that came back to haunt me later when I tried to access my Mum’s health records.

We waited a long time in A&E with little information although I understood why. The priority was my mother and we had to trust the staff knew what they were doing. At this stage, all I knew was that my mother had bad back pain, painful, debilitating and incapacitating but not life threatening. So when a member of staff took us to a nicely decorated quiet room with tasteful pictures on the wall it took a moment for the alarm bells to go off but when they did it was with terrific clang. Your wife, said the on call SHO to my step-father, has been moved to the resuscitation room. Why? We don’t know what is wrong with her she said but she is getting worse.

More time waiting and no information until suddenly we are told we can pop in and see her. It is around three hours since we arrived and two days since I last saw my mother lying on her sofa in her home. Now she looks every inch of her 68 years with dishevelled hair, flushed cheeks and tired eyes. A catheter slung over the side of the trolley and a cardiac monitor blipping away. A blanket loosely covered her lower legs and a hospital gown which had ridden up to expose her thigh. Shocked at this indignity, I reach to pull the blanket over her and tuck it in as best I can. She smiles. She is fine she says. We stay but a few minutes before the porters arrive to take her up to the high dependency unit. The SHO can tell us very little. An infection she says. We need to monitor her overnight. And the resuscitation room? Just a precaution she says.

My step-father sees Mum to the ward and my sister and I go home. What a day. It will be busy tomorrow I think, with clothing to bring and visiting times to arrange between us. I am moving into hospital visitor mode already. I drop to sleep like a stone only to be woken by the phone at around 3am. It is the hospital, mum had deteriorated and I need to go now. I collect my sister from her house and we drive the 20 minutes to the hospital and take the lift up to the high dependency unit, which in reality is just one of the bays on the acute surgical ward. I know this because I have worked in the hospital for a number of years. I know many of the staff, I know my way around, I am normally an insider but not now, now I am an outsider, a visitor. Suddenly I know nothing about anything least of all what is happening to my mother.

We are asked to wait in the dayroom at the far end of the ward, my sister, my step-father and me. The SHO comes to speak to us. She doesn’t know what the problem is but they are doing tests. It is an infection. Mum is much worse. They have taken bloods. They have started IV antibiotics. I ask if the consultant can be called. No I am told, he is a consultant. Isn’t that the point I ask? No, he wouldn’t do anything different she says. We will call him at 08.00am. I am helpless. I know nothing, I don’t know how to push for more, I am tired, upset and I can’t grasp the enormity of what is happening. I am just the daughter, not a vastly experienced, capable, articulate nurse. During the night there is talk of a move to London, a liver transplant and a blue light.

By the time the consultant comes it is too late. She is not even well enough to be transferred to the ITU across the landing. In all this time we have not been allowed in to see her. I am in the day room when I hear the crash call go out and I know it is for her. Nobody comes to us. Breakfast is being given out to the other patients. The ward is warming up for the day ahead. I walk down to the high dependency bed. Curtains around the bed confirm my suspicion. I look in and the crash team are around the bed, defib in hand. My mother is intubated. They look at me. I want to come in I say. A nurse comes out, pulls the curtains behind her. Don’t come in she says. I want to I say, I don’t want her to be alone. Are you sure she says? Yes I say, and she thank goodness, has the good sense to let me. I stay at the top of the bed as they work on her but it is no good, I can see she is not going to make it.

So what next? The staff ‘tidy’ my mother up. We are invited in to say good bye and I ask them to turn the ventilator off which is pointlessly and noisily clunking away at my Mum’s unresponsive chest. I have to stand behind my step-sister who has come over all dramatic. I have no time alone with my Mum (not ever again) and I say a private thanks that I pushed my way in to be with her before the very end came. A super nurse (thanks Emma) and a lovely anaesthetist have a few words with me in the office. I am given Mum’s wedding ring and am reminded of the number of times I have done this same act in reverse. I hand it to Rob outside who is in bits. My sister and I leave the hospital, minus the person who brought us into the world, who can never be replaced and who until just a few days previously had barely had a day’s illness in her life.

And afterwards? Going through the address book to let people (many of whom were strangers to us) know what had happened. Visiting Mum in the funeral parlour and bitterly regretting it. A large funeral, jostling in the front row from the step-sister (I lose and end up on the second row) and the vicar saying my Mum’s name wrong not once but twice. The post-mortem identifying cause of death as bacterial meningitis, fast and furious but potentially treatable. Believing that something went wrong in my Mother’s care but having no way of finding out. And finally, going back to work at the same hospital and on the first day going to see a patient on the same ward where Mum had died.

Taking a deep breath and carrying on.

My time at Hill End Hospital

The chapel at Hill End, now an Arts Theatre

As well as working in theatre during our second year of nurse training at the QEII, we also did a psychiatric placement. This normally took place in the psychiatric wing of the hospital but I asked for mine to be in Hill End Hospital, so that travelling would be easier for me. Hill End was a large Victorian-built mental institution on the outskirts of St.Albans. It operated from 1899-1995, first under the name of Hertfordshire County Asylum and then later as Hill End (after the NHS had claimed it as its own in 1948). It started with 100 male patients and eventually accommodated over 1200 patients of both sexes by 1939. During the war, like many other mental health institutions, it became the base hospital for an inner city hospital, in this case St.Barts, London. Most of Hill End’s patients were moved to other hospitals to make way for the expected war casualties. After the war it settled down to business again as an NHS Psychiatric Hospital and had a number of well-known in-patients including the comedian Spike Milligan. However, by the 1980’s more and more patients had been moved into community projects or small housing and Hill End was much reduced in size. In 1995 (after the Community Care Act of 1990), Hill End closed completely (it is a now a large housing estate).

I did my placement at Hill End in 1984. Although the hospital numbers had reduced by then compared to its heyday population, it still felt like a thriving and busy hospital. I worked in a male admission ward and remember far less about it than I do about Napsbury (see earlier blog entries) probably because I wasn’t there anywhere near as long. I do remember that the staff smoked on the ward and didn’t wear uniforms (which made it tricky to know who was who at times). There was a television in the day room that the staff watched a lot of until one of the patients hurled it at a window. It didn’t go through because of the wire-protected panes of glass but it didn’t work again either. I also remember the ward domestic running in to say a man had hung himself in the toilets and being kept away until he had been cut down (he did survive). I don’t remember the easy, communal spirit there was at Napsbury probably because the patients were much more acutely ill and tensions in the ward were running high for much of the time. However, the staff were friendly and inclusive and I enjoyed my time there.

Over in the QEII, the other students in my group had a difficult time of it and felt much of the care they witnessed was inappropriate or unsafe. After a top floor window pane was pushed out of its frame by a patient, two students complained to the lead nurse about standards of care and their placement was curtailed very quickly. There was a lot of bad feeling from the ward staff to the remaining students and I was glad not to be there. Whistle-blowing was as difficult then as it is now, although policies now aim to protect staff from any back-lash, it is inevitable that feelings will run high on occasions.

Whilst looking for information on Hill End for this blog I came across an excellent resource called ‘Out of Site, Out of mind’ at http://www.stalbansoutofsightoutofmind.org.uk/page_id__74_path__0p2p21p.aspx
There are numerous comments at the end of the piece about the Adolescent Unit at Hill End which reportedly had appalling standards of care. Many of the contributors personal recollections of the Unit are really shocking and I am saddened to think it was all going on whilst I was there. It was 30 years ago but we still periodically get the same shock horror stories about healthcare in the UK (Winterbourne View, Mid Staffordshire Trust).

My placement at Hill End did not make me wish to return to my original roots in psychiatric nursing. By that time I was completely immersed in general care and looking forward to my return to St.Albans Hospital for my final year.

Making a hash of it in theatres

In the early 1980’s nursing students at St.Albans City Hospital undertook their second year of training at the QEII hospital in Welwyn Garden City (where I had done my stint as a healthcare assistant on paediatrics). My first placement there was in the operating theatre suite, another area like ITU, which I was quite anxious about. It was a complete change from the ward environment and it didn’t feel like anything we had learned to do in a ward would help us in theatre. There was no washing or feeding, no back rounds and minimal chatting with the patients. The thing I remember most was that there was nowhere obvious for students to fit in because every job seemed to be much too important for us to be left with.

By the end of the placement we were just about trusted to clean instruments and put them through the autoclave and wash the theatre walls and floors. I say trusted but on one occasion I was asked to run the final set of instruments through the autoclave steriliser at the end of a busy day and managed to make a complete hash of it. The door was difficult to close and I was asked to put some oil onto the hinge. I felt like I was always asking questions and never really knowing what I was doing so when I couldn’t find the oil I didn’t want to go back to the senior nurse and say so. Fortunately there was some oil of cloves in the cupboard which I thought would do fine (oil was oil I thought). So I dropped some oil on the door hinge inside the autoclave and set it to run. After 10 minutes or so the autoclave got really hot and as it did so the smell of cloves (a big pungent, penetrating smell) filled the theatre. I looked on in horror as the smell got more intense but there was nothing I could do about it. I ended up running the machine several times over to try and remove the smell but it seemed to get worse. Having closed the theatre down for the evening I then worried myself sick all night that someone would tell me off when they walked into the highly spiced theatre the next day. Nobody said a word though so presumably the next day’s operating team either liked it or couldn’t smell a thing through their masks!

The theatre suite was run by a senior nurse who had a keen eye for detail and knew exactly what was going on in every corner of the department. She would allocate the students each day by bestowing on them the temporary title of Anaesthetic Queen, Pre-op Queen, Queen Runner or Recovery Queen (we were all girls). Setting out the instrument trays for each days list was a particular challenge for me as I could never remember which order everything went in for the surgeon and of course some surgeons liked their instruments in a different order to others even if it was the same operation. I did assist in recovery on a few occasions and one of the other students had the opportunity to assist in a tonsillectomy (although it was complete disaster as she handed out all the instruments in the wrong order and the senior registrar was so annoyed he said he would not have student nurses in with him again).

Everyone in the department wore theatre blues including the students so it was difficult to know who was who. Despite this there was a very clear hierarchy which meant you could get it badly wrong if you didn’t know who was an incredibly important consultant (as in who thought they were an incredibly important surgeon) and who was just another student nurse.

Some of the surgeons had us quaking in our clogs but despite that watching them operate was fabulous. Although I found it hard to feel at home in theatres I did find the whole business of poking around inside the body amazing. Back then we didn’t have the technology that theatres do now, so most surgery was performed direct, there was little key hole (if any) and I don’t recall any camera guided surgery. The orthopaedic surgery in particular was (and still is) quite basic in the sense it was all saws, retractors and brute force.

All in all, I was enjoyed my experience but was relieved to leave and get back the world of talking patients and knowing exactly my place as a 2nd year student with a long way to go yet.

Pressure ulcers back in the day

Pressure ulcers seemed to be few and far between in the early 1980’s although that is probably my rose- tinted glasses talking. As mentioned before routine back rounds were the norm in all adult wards, when each patient was visited at least every two hours to be stood, walked, toileted or re-positioned. The news that vigorous rubbing of pressure areas can cause friction damage or possibly rupture the micro-circulation hadn’t hit us yet and we were still frantically rubbing those hips, heels and bottoms in the belief that it would bring the blood supply back into the oxygen starved tissues. There is of course something about the regularity of visits to the patients and the activity of walking, toilet and turning that, in itself, is a great way of relieving pressure, but heaven knows how many were prevented and how many were caused by our ‘helpful’ intervention.

I’ve mentioned bed cradles, pleated sheets and monkey poles before but that’s not all we had. Alternating pressure mattresses were not in wide use (if at all) but we did have a simple ripple mattress which overlay the basic hospital mattress. The ripple mattress ran on a little motor but that was as sophisticated as it got at

A modern ripple mattress

St.Albans City Hospital. There were none of the weight sensitive mattresses that we have now, nor the all-important lowering of pressure under the heels or the rapid deflation switch for CPR (you cannot do effective chest compressions on an air mattress). The cover of the mattress had a limited stretch to it didn't contour to the patient in the way that today’s highly flexible three way stretch materials do.

The mattress underneath, usually the standard NHS foam mattress by that time, had a marbled pink cover over it with a zip along the side and end. This cover had a really limited stretch to it and in time became infamous for its ability to create a rigid ‘hammock’ for the patient to lie on. This meant that instead of flexing to the patient’s shape and allow the body to sink into the foam underneath the cover stayed fairly rigid, suspending the patient (as in a hammock) above the foam. The hammock effect creates higher pressures over bony prominences instead of dispersing them by increasing the body’s surface area contact with the foam.

The other problem with the cover was that it wasn’t very good at preventing body fluids from soaking through to the foam underneath (partly because the mattresses weren’t replaced often but mainly because they weren’t effectively waterproofed). This problem became more apparent when the use of plastic overs and draw sheets to protect the middle of the bed reduced, thus removing an important additional layer of protection from the mattress cover (they went for good reason, the draw sheets were rough on the skin and the plastic under layer caused the patient to sweat). Many early tissue viability nurses (and infection control nurses) will remember unzipping the mattress to check the foam inside only to find large stained patches in the centre of the mattress. And the stains weren’t all on the inside either, often there would be large, dark stains on the cover itself, an odorous reminder of some previous occupants trauma and distress. Many tissue viability nurses, myself included, would take photos of these mattresses to shock management into getting them replaced.

Nowadays we can buy mattress covers that are very sophisticated in their ability to conform to body shape along with providing excellent waterproofing. High spec products will also have neatly concealed zips to prevent fluids getting into the foam through the zip area although mattresses still need replacing regularly to ensure maximum benefit. As to the foams today, they are also much more sophisticated. Even a basic mattress should be able to offer some pressure re-distribution, whilst the more advanced ones are really effective in spreading load and giving comfort. The memory foams will bounce back into shape too unlike their ancestors which would flatten, or ‘bottom out’, after months of heavy use leaving the patient as good as sitting on the hard metal bed base. Not good for pressure areas and so uncomfortable for the patient.

Something else we used a lot of in the 80’s was sheepskin; sheepskin bootees, sheepskin overlays and

elbow protectors. Real sheepskin products are very absorbent (think sheep in the rain on a mountain side) and soft to touch but the type we used was synthetic and usually been through the hospital laundry so many times it was horribly lumpy. Not comfortable at all and certainly no good for protecting the skin from pressure.

Another lumpy product was the fibre filled overlay which sat over the base mattress and was supposed to offer the patient comfort and pressure reduction. Again, the frequent visits to the laundry meant these products were far from comfortable and today’s at risk patient is more likely to be nursed on an alternating air pressure mattress which will provide pressure reduction on a cyclical basis or a low air loss mattress which will provide a constant low interface pressure between skin and mattress surface.

In earlier times water filled mattresses were used for pressure reduction although by the time I trained they

had been mostly replaced by the ripple mattress. The principle of water flotation remained of interest to the 1980’s nurse though and many who were around at the time will recall filling surgical gloves with water, tying the end like a balloon and balancing the heel on it. This precarious device was difficult to position and although the principle was reasonable enough (minimise and disperse the interface pressure) it was unlikely that it did any good. Particularly when people taped the glove to the foot, the glove leaked, the glove was over or under filled, or filled with water that was very hot or very cold, the foot moved, there was a skin reaction to the latex (I think they all had latex in them then)….

 

One final item that I recall was the ‘doughnut’ or ring cushion. Here the principle was to rest the heel or bottom onto a ring shaped object in-order to relieve pressure in the centre. The seating rings were usually made of foam and the heel ones we usually made ourselves but I can’t recall how (hoping it will come back
to me or perhaps someone will give my memory a nudge). In later years it was suggested that the inner ring could in fact exert a line of pressure around the vulnerable skin area thereby further reducing the supply of blood to the area. We haven’t recommended them for many years because of this but only this week a student asked me about them because she had seen one in practice and I then found several styles for sale in a medical supplies catalogue. Either the evidence isn’t clear enough or the message just hasn’t got through on this one!

Despite all this, as I said at the start we did not seem to have so many pressure ulcers as we do today. But then our patients had longer to recover in hospital, there were fewer high dependency patients because survival rates weren’t so good nor surgery so complex. We had more hands on nurses because we students were part of the ward team and we had that back-round, checking skin condition regularly and re-positioning routinely. We had fewer older patients than today and we were not struggling to provide care within a context of constant pressure on costs, staff and beds. However, this was all set to change, as we moved toward individualised nursing care in the 1980’s what we gained on the one hand (holistic patient focused care) we lost on the other with task orientated nursing care thrown out the window along with the certainty that all the fundamental caring tasks that every patient needed were getting done. Today nurses are trying to re-dress the balance without losing the great strides the profession has made in terms of providing patient-centred, holistic, nurse led care.

Still the 1980’s were a time of great innovation and the pioneers of pressure care were set to really shake things up. Click here to hear Pam Hibbs talking about her ground breaking work at Hackney Hospital in the late 1980’s http://health.hackneysociety.org/page_id__142_path__0p10p43p.aspx ). She and many others started to question why pressure ulcers were on the increase and look at what could be done about it. It was Pam Hibbs who famously said that 95% of all pressure ulcers could be prevented. Its a mantra that many nurses have taken up again today and whilst pressure damage is not the sole province of the nurse, there is no doubt that nurses are supremely well placed to lead on eradicating this problem for the vast majority of patients.

Next week: Moving to the QEII and working as a student in Theatres

Nightingale wards and Nelson's Inhalers

Previously I mentioned the ward sister who called everybody Sweetie Pie regardless of age, race or gender. It made me think back to the ward she ran (and I use that word loosely) which was a single storey medical ward in one of the oldest buildings in the hospital. The ward was set out in ‘Nightingale’ fashion with beds down either side the length of the ward and a Sister’s office at one end with a sluice at the other. All the patients were male aside from the occasional female patient in a side-room when beds were short elsewhere. Just like ITU the ward relied on oxygen and air tanks for its many chest patients and much time was spend manoeuvring these tanks around the bed areas.
The biggest tanks sat shoulder high and were caged in wheeled metal trolleys (as they are now) with a big metal bar on the side for a handle. Moving the tanks meant tipping the cage back on to its two wheels, holding the weight steady and pushing or pulling the trolley into position. There was no more bed space then than there is now and it was an awkward business working in such a limited area; the tanks were heavy and the cold, hard metal of the cage painful if knocked into. Moving around the patient to wash them or provide mouth care, meant working around the tank, the bedside table, the locker and the bed itself. There might also be cot sides, a bed cradle and a monkey pole on the bed (for the patient to lift themselves up with) to contend with.

In every hospital that I’ve worked in since, space has been a problem in wards and side rooms alike. Only recently I was in a side room in a modern hospital and the patient needed a hoist to move from bed to chair. The space limitation of the room (which only had the bare necessities in) was as much a risk to the patient and ourselves as the actual moving procedure we were carrying out. Whilst there is guidance on minimum bed space even now it would seem not all hospitals meet this http://www.informedesign.org/Rs_detail.aspx?rsId=3555

Caring for medical patents can be hard on the back, with patients often highly dependent on the nursing staff to wash, feed, toilet and move them. Having said that, male medical wards had the distinct advantage over female medical wards because the men could use a urine bottle whilst the women always had to be lifted onto a bed pan or commode (the ‘she wee’ hadn’t been invented yet!).

Personally, I liked the variety of working in medicine and I loved the sense of involvement with the patients because they were often in for longer than the surgical ones. Despite the Ward Sister’s out of date approach to nursing (she wore a frilly white cap, sat in the office for long periods of time, fawned over the doctors, avoided the patients and went to the hairdressers on Friday afternoon during shift time) it was a friendly ward and I learned a lot about all round nursing care. At home now I have a Nelson’s Inhaler (bought second hand) which still smells of tincture of benzoin (Friar’s Balsam), one sniff of which takes me back thirty years. They were brilliant for ‘chesty’ patients; we would put a teaspoon of tincture in the china inhaler, add boiled water, sit it in a deep plastic tray and pack around with towels. Then the patient would lean over the inhaler and put the mouthpiece in his mouth and gently inhale. Very soothing and worked a treat.

One advantage of the Nightingale ward was the sense of camaraderie that sometimes developed between patients. Although it is a very public space to be ill in, patients can also see and speak to each-other easily, they can see where the nurses are and they have a sense of the ward routine and activities so there is less risk of isolation. Privacy and dignity was not easy to achieve though and having your bowels open on a commode with just a thin bit of curtain between you and the man in the next bed either side (plus their family if you chose to go between 2pm-4pm or 7pm-8pm) must have caused many a bout of constipation.

The curtains round the beds would rarely stay closed. If the curtains went to be laundered the replacement ones were never long enough or wide enough. No disposable curtains back then either. Nor were there any duvet covers as there are in some wards now. Every bed was made properly with sheet corners folded in and top sheets folded back to show approximately 12 inches of white over the blue bedspread (blue because it was the men’s ward; the women had pink of course). When we made the beds we would put a central pleat in the top sheet to ensure some looseness over the patient’s feet because tight sheets over the foot cause pressure damage and foot drop.

Now, pressure damage, that’s something I will definitely be coming back to…

Civility - what has it got to do with nursing?

A slight departure from the chronology this week, with a reflection on an issue dear to my heart, civility. Civil behaviours convey a level of respect and courtesy to others that facilitate social co-operation and order.  They are as necessary for healthcare communities as they are for any other social community, tempering emotions in difficult circumstances and smoothing the way for people to communicate and work together effectively. As a cornerstone of good nursing practice, civility influences how patients and their families experience all aspects of the care they receive.  

At the other end of the spectrum, incivility conveys a lack of respect or tolerance for others, undermining the sense of common good that society needs to function effectively and peaceably. In healthcare, it can be at best irritating and at worst seriously destructive, impacting negatively on physical and mental well-being.  Whilst civility keeps the focus on the primacy of the patient experience, incivility allows judgement, bias and personal preference to intrude, often to the detriment of the patient. Nurses therefore have a professional and moral duty to behave with civility at all times and nurse education has a key role to play in the development of civil behaviours as part of professional formation. In essence it is about being nice to each-other and in nursing I think that has real significance for how we care for patients (and how patients feel they are being cared for).

 

My personal interpretation of civility and incivility is born of a collection experiences which have influenced my perceptions, attitudes and expectations in relation to how people behave to each-other. Some of these go back to my earliest experiences as a nurse and of course further back to my childhood. Raised in a polite family, we were taught the importance of writing thank you letters after receiving gifts, we went to Church to say thank you for having food on the table and we gave up our seats to older members of the family when asked to. After tea we asked for permission to leave the table, sat quietly whilst my father watched television and went to bed without arguing. At school teachers were respected and children, including myself, were well behaved. The same standards of civility were expected when I commenced nurse training, aged 19. Student nurses stood up when a senior nurse came onto the ward, addressed patients and colleagues by their title and surname and always took the stairs to leave the lift free for patients and relatives to use.

 

Variations in standards of behaviour became more obvious to me when I entered into adulthood. Not long after I started training I was admitted to my training hospital for an operation on my feet. Afterward I was lying on the bed with both feet plastered heavily, feeling sick and in a lot of pain, particularly in my toes. When the night nurse came on duty I asked her if she could put the bed cradle (a device to lift the sheet clear of a patient’s feet) in for me. She turned and told me that if I wanted it so much I could get up and get it myself. That nurse, an older and apparently experienced staff nurse left me feeling shocked and embarrassed (and everyone else in the four-bedded bay not daring to move a muscle). Needless to say I didn't ask again. I faked a bowel motion two days later and got out of there as quickly as is possible in a wheelchair with flat tyres and no foot plates (shortages in the NHS are nothing new). 

On another occasion, my Grandma, who had cancer, was admitted to the surgical ward whilst I was a student on placement in the nearby maternity unit. One morning I received a message to go up to the ward quickly because she was very ill and the rest of the family had been called in. She died whilst I was there and after the formalities had been dealt with I returned to the maternity ward to explain to the ward sister what had happened. She said nothing about my Grandma's death, just looked me up and down and told me not to come back on duty until I had a clear nasal swab because “we have no idea what germs you might have picked up on surgery”. Not surprisingly, midwifery didn't feel like a possible career option after that.

There were other incidents that came later, after qualifying as a nurse. Such as the man who came to the ward every week to visit his mother, drunk and verbally abusive or the consultant who swore in-front of an elderly patient because the nurses refused to strap a wooden plank under the patient’s leg to keep him still. There was also a more subtle but equally corrosive type of incivility. The vascular surgeon who introduced me to his team as the Bottom Nurse (I was a skin care specialist in Enfield by then) and the ward sister who called all her patients Sweetie Pie, regardless of age, ethnicity or gender. Ten years on, as a nurse educator, I continue to see all sorts of examples of incivility in my day-to-day working life; people talking over one another in meetings, students late to class, people blocking corridors, aggressive emails, smoking outside open windows.

I am shortly having a 'coffee and conversation' with colleagues to try and tease out what we understand by these terms, incivility and civility. After all perhaps my views are very different to those of others. Maybe its an age gap thing, or a culture issue, or a gender perspective.

 

Whatever it is, it is definitely something to think about...