Intensive Care Unit - a change of pace

After my 8 week stint in A&E and a short period back in the School of Nursing, I went to my next placement which was the Intensive Care Unit (ICU). After the hustle and bustle in A&E, which in the end I had quite enjoyed, the relative stillness of the ITU patients was quite daunting. Suddenly the two-way chat had gone, to be replaced by the hushed shunts of ventilators and the quiet blips and peeps of life-saving machinery.

The pace of work in ITU was completely different. It was a small 6 bedded unit, very unsophisticated by today’s standards but still daunting to an inexperienced student. With only a few patients to concentrate on and 'afternoon only' visiting times strictly observed, there were fewer people in the Unit and everything seemed much calmer than in A&E. With a controlled entry system, everyone who entered the Unit had to have a reason for being there. If a patient hit a crisis the team would swarm around them, like bees in a hive, each person seeming to know their individual role. As students we were assigned to a member of staff who usually worked with just one patient throughout their shift; occasionally two if their dependency was slightly lower. Our patients were wholly dependent on the staff and the machines that surrounded them. Everything had to be monitored and recorded from urine output, to oxygen saturation to cardiac rhythm. We still had oxygen in tanks in those days and even the supply display had to be checked regularly to ensure the porters replaced the tank before it emptied completely. No running supply of air or oxygen from a valve in the wall! 

Nursing ITU patients felt like a very one-way kind of nursing, much more technical and far less patient-nurse interaction than in the wards. Lots of communication through other means though and for many nurses the relationships with patients and family through these very intense periods of illness were very rewarding. For me though, the ITU experience was less than satisfying and I couldn’t wait to go back to the hustle of a ward placement area, not least because I could stop worrying about what was coming through the doors next. It was not until years later, as a Tissue Viability Nurse visiting ITU regularly, that I suddenly understood why some people enjoyed ITU nursing so much. What had seemed so daunting as a student became fascinating as an experienced qualified nurse and as is often the way with nursing, I started learning all over again.

Next week: Compassion -  a dying art.

The thrill of A&E: armchairs, fleas and pressure ulcers

In my first year of nurse training I was placed for 8 weeks in the Accident and Emergency (A&E) department which was housed in a separate, single level building on a steep slope just down from the main hospital (St.Albans City Hospital) . It was old, shabby and poorly equipped. The small waiting room was frequently overcrowded with people sitting on narrow wooden chairs, waiting their turn. Patients requiring x-ray or admission had to leave the department and walk, or be wheeled, up the slope to the main hospital. As this required being out in the open, patients on trolleys were covered with plastic sheeting if it was raining!

The department was run by a senior sister, called Sister Plum* and a junior sister called Sister Elton. Sister Plum was small and fierce with an enormous bosom that left little room for anyone else in the tiny department office. What Sister Plum lacked in humour, Sister Elton made up for. She was approachable and cheerful, a good teacher and an active Union member. On one occasion when I reported sick with a sore throat, I was asked by the Nursing Officer in charge to provide a throat swab to send to the pathology lab for culturing as proof of illness. Outraged at what I saw as a basic lack of trust between employee and student nurse as well as an abuse of position on the part of the hospital management, I wrote to a well known nursing journal to give vent to my feelings. Then, not really wanting to rock any boats, I signed the letter ‘anonymous’ and posted it off, not expecting to hear anything more about it. The next I knew of it was that it was pinned to the Union section of the department information board in black and white print, torn from the journal's weekly letters page. Although Sister Elton pointed it out to all the staff she never mentioned it to me directly; however, I was sure she knew who the letter had originated from. This might not have mattered had I not, to my ever-lasting shame, actually had a sore throat but two tickets to see the Rolling Stones at Wembley Stadium in London. My indignation at the challenge to my integrity was so intense that I had all but forgotten that I was actually completely in the wrong. So, 30 years on I would like to say here and now that it was atrocious behaviour on

my part and I am sorry to all concerned. Guilt is a powerful emotion and rest assured the guilt I felt was enough to ensure I never ever, ever played 'hookey' again, throughout my career. Students beware, nurse tutors were young too once and we know the kinds of temptations you face!

I had been worried about my A&E placement expecting to see lots of cardiac arrests and road traffic accidents. However, my enduring memories of A&E were of more mundane things. There were lots of finger injuries (as common then as they are now) and I quickly learned how to trephine a nail bed heamatoma using a spirit lamp and paper clip and then to apply a neat and firm finger stall to keep the dressing on. There were also plenty of fractures, typically clavicles, scaphoids, tibias, fibulas and Colles (wrist) and lots of near misses in the form of sprains. Bandaging was still quite an art form at that time and we spent hours in the classroom practicing how to apply crepe bandages in the spiral, figure of eight, reverse figure of eight, ‘toothache style’ and spica methods on each-other. Fortunately, the more old fashioned many tailed bandage had been dropped by then (it looked like it needed many nurses to apply it) but we still re-rolled bandages and gauze ribbon for re-use as long they were clean. I had very particular experience of those long narrow pieces of gauze as I had been a patient myself in this same A&E as a child. We only lived two roads away from the hospital and when I tripped over a long-handled garden fork on our concrete garden path and my nose wouldn’t stop bleeding, my Mum whipped me over to the A&E to see the doctor. It must have been bad because I was a regular ‘nose bleeder’ and generally it just trickled to a halt in its own time. However, on this occasion it wouldn’t stop so the doctor packed it with what felt like yards and yards of ribbon gauze. It was pushed up and up into my nasal passages until it made my head throb and my eyes sting. I’m surprised it didn’t just start again when it was taken out a few days later. My Dad wasn’t very pleased about the whole episode because I’d bled on my new brown duffel coat and stained the new concrete path dark red as well.

More serious injuries and illnesses were few and far between but one case sticks in my mind. He was a frail, elderly man with multiple pressure ulcers around his sacral and buttock areas. The ambulance team brought him in sitting in his armchair where he’d been quietly decaying for weeks into the soft upholstery beneath him. They had to carry him through the small department waiting room before settling him into treatment room, so every head in  the place watched him being carried through. When the door was shut, we literally had to cut him out of the chair, after which we washed him as best we could. All this whilst wearing surgical gowns aprons, hats, masks and gloves because of the fleas jumping off him. He eventually ended up in theatre for a full surgical debridement to remove not only the dead skin from the ulcer bed but the remnants of the chintz cushion cover as well. I don't know what happened to him after leaving A&E, one of the down sides of working in the most transient of all hospital settings.


Trephining the old fashioned way - a bit before my time

Another of my worries about A&E was seeing a fatality following some kind of major trauma. Although I had seen a couple of dead people at Napsbury, they were elderly and died peacefully, whereas death by crash, crush, burn or whatever other means, I imagined to be very distressing for all concerned. So when a person who was BID (bought in dead) arrived outside the department in an ambulance, I asked to go and see the body. I thought it would help dispel my fears of not being able to cope although I didn’t explain this to Sister Plum who thought my request  very strange. She said I could go in on my own if I was ‘that interested’, so caught between feeling rather silly to have asked and not wanting to back down, I went out to the waiting ambulance and opened the back doors and stepped up and in. The BID (horrible term), was on the trolley with a red blanket over him (red was used to mask any signs of blood). He was an elderly man, lying on his back, eyes closed and looking very peaceful. No trauma, no blood, no ghastly re-arrangement of the limbs. I returned to the department none the wiser about major traumas and remained wary of any emergency arrivals to A&E but mindful of Sister Plum's evident disdain, I did not ask to see any more BIDs. 

Next week: all change for ITU

*Names changed

1980's elderly care: Australian lift and the coming of Roper

During my three years I was fortunate to see a wide variety of specialties and experience a wide range of nursing challenges. My first placement was in an elderly care ward where I worked for 12 weeks. The ward was in a one storey building, a modern addition to the old Mid Herts. site on Church Crescent close to our accommodation (St.Albans City Hospital if you haven't been on this journey before!). The ward was set out in a traditional nightingale style, with beds lining the walls either side of the ward and ancillary rooms such as the kitchen, bathroom, treatment and sluice rooms situated at either end. All of the patients were female and over the age of 65 with a high prevalence of conditions such as stroke and cancer and chronic disorders such as Parkinson’s disease, diabetes, chronic obstructive airways disease, emphysema, rheumatoid and osteoarthritis and heart disease. Patients with multiple pathologies were as common then as now in elderly care wards often requiring complex treatment programmes from a range of professionals such as nurses, dieticians, physiotherapists, pharmacists, speech and language and occupational therapists and of course the physicians.

Work in elderly care was physically demanding and then, as now, space in each bed area tended to be limited making it hard to work efficiently; equipment aids were also in relatively poor supply when compared with today’s NHS hospitals. We had a bathroom hoist with a couple of slings to accommodate different sized patients (one often in the wash or on loan to our counterparts in the male elderly care ward), monkey poles above the beds and pump up variable height beds. Some patients were issued with turning or sliding boards to aid transfer but for most patients manual handling was the norm with lifting techniques such as the Australian lift in common use. This lift entailed two people standing one either side of the upright, bed-bound patient. Each person would then put their shoulder beneath the axilla of the patient, link their hands beneath the patient’s upper thighs and together lift the patient up the bed. This lift required co-ordination, strength and a fair amount of trust on the part of the patient. Unfortunately for the nurse it was highly likely to put a strain on the neck or spine and thankfully, in the UK at least, it is now recognised as an unsafe lift for both nurse and patient (shoulder injuries, skin damage through shearing) and should therefore never be used. Back then though, most of our patients were highly dependent and there were many occasions when nurses were at risk of back injury because of poor equipment, training, staffing and/or awareness.

The Australian Lift - not as funny as they seem to think!

Working in an elderly care ward was hard but it gave us an opportunity to develop core nursing skills which stood us in good stead throughout our nursing careers. The ‘back-round’ system of care ensured that every patient was visited on a regular basis, re-positioned if necessary, toileted and given a drink or fed. Mouth, hair and skin care were routinely carried out along with general hygiene care and mobility support  (today's use of Intentional Rounding is not as innovative as some would make out).

However, the regulated, task-oriented approach which had been in use for so many years fell out of favour as the profession moved in the 1980’s to adopt a more individualized approach to care. The work of nurse theorists such as Nancy Roper, the UK born nurse who defined nursing in the context of a model of daily living, provided a framework for care which allowed the nurse to adopt an individualised, holistic approach to care which encompassed all the patient’s needs from eating and drinking to sleeping, working and playing, breathing, maintaining a safe environment through to expressing sexuality, controlling temperature, elimination, mobilization, communication and dying. When used effectively the model, which is in widespread use around the world today, ensures important elements of care are not overlooked. The work of others such as Dorothea Orem and Virginia Henderson was equally influential, although it was usually the case that there were many years between the development of the theory and the implementation in practice.

However, delivering individualised care in the way Roper and others envisaged it is difficult in a modern healthcare environment. The pressures of time, staffing, targets and the complexity of patient’s needs often reduce nursing to a list of key priorities, the things that must be done rather than the things that should be done. The modern dilemma (in the UK anyway) is how to keep to an indivudalised approach to nursing and still ensure essential care for all is carried. 

Next week: Fleas and more in A+E

Being assessed in practice - 1983!

In 1983, assessment of clinical practice took the form of four practical examinations spread over the three year training period (I know it sounds antiquated but remember this is pre-project 2000 and the concept of continuous assessment hadn't quite crept in yet!). The practical exams were nerve wracking because they took place in the clinical area in front of everyone and also because, like the written exams, they had to be passed to progress to the next stage of training (so maybe not so antiquated after all).

I remember being worried about my total patient care exam because I was working in paediatrics (St.Julian's ward) for three months and there weren’t many suitable children to provide total care for. The exam required us to demonstrate skill in supporting nutrition and toileting needs and performing general hygiene and mouth care. However, the children were often in for relatively minor surgery (such as circumcision or inguinal hernia repair). They would be self-caring on admission, briefly incapacitated by an anaesthetic then quickly up and running about again before heading straight out through the exit at full speed. Children in for other reasons such as orthopaedic correction would often be fixed to some kind of metal frame for weeks on end but were still perfectly able to eat, clean their teeth and make mischief. In the end the ward sister took pity on me and said she would do my assessment with a little boy who was recovering from a pyrexia of unknown origin (PUO). He was fully independent, if a little weak, and about to go home. With his mother’s consent, I went through the motions of helping him into the big ward bath, preparing his lunch, encouraging him to clean his teeth and standing outside the toilet door asking him if he needed any help. Everything was very straight forward and the Sister duly marked me as passed but it hardly stretched my skills in the way someone who was assessed whilst working in elderly care would have been. This was the chief limitation of having to do the assessment at a certain point in time, it meant it could be more tick box than meaningful.
 As well the 'total patient care' assessment, there was drugs, aseptic technique and  ward manangement (always the grand finale). All I remember about the drugs one was that we had to undertake a drug round with our assessor, perform various calculations and memorise two drugs in detail to be tested on orally (tested not taken I hasten to add), My chosen drugs were paracetamol and digoxin. Educationalists, including myself, question the benefit of these very superficial approaches to learning (memorise - recall - recite) but to do this day I remember more about those two drugs than any other.

The aseptic technique assessment was a joy to behold and a horror to complete. At the time we used disposable dressing packs with forceps, gloves, solutions tray, apron and gauze. We used a non-touch technique, had 'clean' and 'dirty' hands and worked in a positive air flow treatment room wherever possible. The assessment started with trolley preparation which we had to clean from top to bottom making sure the wheels were last. For my assessment I chose  to do a partial removal of a corrugated drain from a surgical wound. This procedure involved the removal of a safety pin from the drain (this secured the drain in position, presumably this would now be stiched into place), the adjustment of the drain position and the re-insertion and closure of the safety pin. The wound area would also be cleaned and a sterile pad applied. All of this would be done with a pair of forceps and no-direct hand contact (not even with gloves on). Truly a challenge. I passed first time so perhaps an early indication of my eventual career path.

It all sounds very labour intensive now but the assessments for total patient care and aseptic technique did thoroughly test the ability to apply a procedure correctly and taught us a lot about doing things the right way. I think that learning the right way to do something in totality and then assessing it formally, with a bit of pressure in the mix,  fixes it in your mind for a long time. Habits when formed are hard to break (bad driving habits spring to  mind), so getting the right habit formed in the first place is very important, it then becomes routine, ordinary, the norm. It is from this secure position that nurses can make informed decisions about modifying practice where necessary e.g. the patient who is in their own home with an infected wound and not a dressing trolley in sight.

My ward management assessment took place on an acute medical/cardiac ward. It was a ward that I spent most of my time being in a state of stressful high alert because I had managed to go through my three years with very little experience of cardiac arrest; I was convinced that this placement would render me a 'rabbit in the headlights' in the event of a patient collapsing pulseless. I do remember the  lovely staff nurse who helped prepare me for the assessment (no qualified mentors then, just willing qaulified staff). I was working with her one morning and it was very busy indeed. I noticed she had a long written list of things to do such as booking appointments, arranging discharges and talking to relatives and I asked if this was ok to do for the assessment. Absolutely she said, how else would you remember it all? I had honestly thought it would necessary to have it all memorised much as we had to do for the drugs assessment, Having said that we were expected to know our patients extremely well and whilst notes about patients were permitted, we would be expected to give a  no-reference-to- notes verbal report about them to the ward sister, night sister or clinical tutor on demand (standing up straight, no cardigan and no coffee cup in sight).

Today, the problem of assessing the right skills, in the right place and at the right time remains a thorny one for nurse education. There is a real challenge in finding enough clinical placements to ensure all students have the same kind of exposure to the same kind of experiences as well as the same opportunities to develop a common set of core skills. One advantage of nurse training in the 1980’s was the commonality of experience with every student having a placement in theatres, midwifery, intensive care, general surgery and medicine, elderly care, Accident & Emergency (A&E), paediatrics, gynaecology, orthopaedics and the community.  The clinical teachers came out to the wards regularly to work with the students. They were highly visible and clinically credible, something which is difficult to achieve now with nurse educationalists being located in University buildings, the majority of which are far removed from the clinical placements they serve. Whilst there are echoes of the past in today’s link tutor roles, the context is quite different not least because the partnership between clinical placement and higher education is now based on a contractual obligation rather than the ‘in-house’ partnership of old. All in all a very different environment for today's student to work in, not necessarily better or worse but different.

Next week: Elderly care, my first ward at last.

Getting our nursing uniforms and meeting the teachers

This week we settle into our new home, get our uniforms (at last!) and meet the teachers...

In the early days of these nurses residences (before my time as a student), a ‘Home Sister’ would stay onsite and ensure the rules and regulations of the Hospital were upheld, including the moral conduct of its nurses. Homes were strictly single sex and there was no staying out late at night and certainly no sneaking in boyfriends. Even in my day there was a Home Warden who kept an eye on us although fortunately (given how close we were to St.Albans’ plentiful choice of 53 pubs) there was no late night curfew.
 

Slightly before my time..

We had to keep our rooms clean and were responsible for laundering and ironing our own clothes, which usually meant several ironing boards cluttering up the corridors. Each room had a single window and a deep window sill inside and out and it was common to see pairs of shoes on the outer sill, being given a much needed airing after a long run of shifts.
The Church Crescent site also housed two elderly care wards and a canteen. We congregated in this canteen on the next day for breakfast but I don’t remember ever going back afterward. Despite the fact that breakfast was very cheap, it was also very early and awkward shift patterns soon made us value every spare minute in bed. We didn’t turn down the free meals on night duty though, left over from the day shift they were left in the chiller cabinet in the big canteen on the main hospital site on Normandy Road. First come first served, so early break on a night shift was very popular. Like most students we didn’t waste a chance to turn down a free meal often.                 

Over the next few days we were issued with our uniforms; pale blue check dresses (standard NHS wear), mid-blue nylon webbing belts (called Petersham belts) and dark blue thick wool cloaks with a red lining. One of the last groups ever to be issued them, I was to regret ever letting mine go at the end of the training although we were told we could keep them if wanted. The ladies in the sewing room (yes, there used to be a sewing room in all hospitals) did alterations as necessary, fitted the belts individually and gave us our caps; stiff card with a thin blue strip around the top to denote our status as first year students, held in place with white Kirby grips. We had been told to bring flat black shoes and pale brown tights to complete the look. When everyone was properly uniformed, a class photograph was taken outside on the lawn by the School and at last the May 1983 set was ready to go.

The School of Nursing was situated in its own building on the main hospital premises at the Normandy Road site. It was a single storey building staffed by nurse tutors and clinical nurse teachers. The two nurse tutors, Mrs. M. and Mrs. Lewin dressed in white uniforms and taught us the theoretical aspects of nursing care such as anatomy and physiology, diseases and conditions and the function of different body systems.
They also taught us clinical skills such as how to pass a naso-gastric tube correctly. This we did on each-other in the mock ward area, withdrawing gastric fluid to test for hydrochloric acid with a strip of litmus paper and puffing small amounts of air into the stomach (we hoped) with a syringe whilst we listened with a stethoscope for the tell-tale gurgle of stomach contents. There were no guide-wires or positional check x-rays as became the norm later. Naso-gastric tubes  (Ryle’s tubes were used for feeding as well as drainage) then were uncomfortable and inflexible, making us cough and gag as they went down, so practicing on each-other made us much more careful when we passed them on real patients, knowing full well how unpleasant it was. Fortunately we weren’t required to try out urinary catheters on each-other.

Ouch!

Mrs. M. was the more senior of the two tutors and was rather scatterbrained and accident prone. She often fell over things in the classroom and although very kind she did seem to lack the kind of everyday common sense required to make an efficient and effective nurse. She once instructed us in ‘washing the bed bound patient’s hair’ using the resuscitation model (known by students everywhere as Resusci Annie) as the surrogate patient. When Annie’s blond nylon hair was shampooed it became badly knotted so Mrs. M told us to remove her head and bring her into the class to dry her hair with the hair dryer whilst she carried on with the next lecture. Annie’s head was sat on the front desk and the hair dryer set to warm. Within minutes the nylon hair meshed together in a melted clump and the smell of burnt plastic filled the room. Poor Annie never did recover her looks nor Mrs. M her composure.                                                                                                                                     

The clinical nurse teachers were Ita Blakey, Laureen Hemming and Peggy Morris (of course they were not known by their first names any more than school children call their teachers by their first names now) . They dressed in dark green nurses’ uniforms and taught us on the wards, focusing on the more practical aspects of nursing care such as how to perform a bed bath and how to set up a sterile field for a wound dressing. They also oversaw the four practical exams we each had to do as students; total patient care, aseptic technique, medicines round and ward management. These were nerve wracking and necessary, each successful one marking another step toward the final exams and (hopefully) qualification.                         

Next week: being assessed in practice!

Starting my training - 30 years ago!

During my time as a nursing assistant in paediatrics at the QEII in Welwyn Garden City, I started applying to become a student nurse. At the time most nurses were trained in a School of Nursing attached to an acute hospital. Training was delivered by the nurse tutors who taught nursing theory in the classroom and clinical teachers who taught practical skills on the wards. It led to the qualification of either State Enrolled Nurse (2 years) or State Registered Nurse (3 years), a two tier system bought in when nurse training was standardised as part of the NHS formation in 1948. Once qualified the SEN worked at a mainly practical level and always under the supervision of the more SRN nurse. Opportunities for promotion were limited although many enrolled nurses were highly experienced and skilled at what they did. The State Registered Nurse worked as the more senior of the two and was able to progress to senior staff nurse, ward sister, nursing officer, matron etc. As a registered nurse, she or he was able to make decisions about patient care including the management of wound care, drains, drips and sutures, administer a wide range of drugs including controlled and intra-venous drugs, accompany the doctors on ward rounds and lead the nursing team as required.

 



As the training for SRN was more demanding that of SEN, Nursing Schools required their SRN applicants to have a minimum of 5 O’levels. The more popular Schools could demand A levels as well. Some training places were highly sought after, a relic of the times when training schools around the country offered vastly different types of nurse training programmes. The best of these (includng of course Florence Nightingale's own school at St.Thomas') would only select well-educated young women from 'good' families.  Living close to London, I was within easy reach of Barts (St.Batholomew’s Hospital) and Guys and St. Thomas’s (before the merger), three top Schools which were still taking their pick of well qualified school leavers. However, as I was not an overly well qualified school leaver I decided to apply to the slightly less prestigious (although still very sought after) Hammersmith Hospital in West London, on the basis it was in London and therefore I would have a good social life. Although Hammersmith did accept O’level applicants they made it clear that A level applicants would have priority unless the O’level candidate was of exceptional quality. I was lucky then to get called for interview, probably on the basis of my nursing assistant  experience rather than my rather paltry collection of hard-earned O’levels.

The grand old Hammersmith Hospital in 1984                                                                                                                                                                             All I remember about the interview was that the hospital interior was beautiful. All varnished wood and tiled floors, with big heavy doors and tall windows. It looked grandly old-fashioned and seemed full of important people but sadly I was not to become one of them. After sitting through an interview paneled by three stern faces, they very nicely said good try but no can do. I didn’t really mind, I had been offered a training place in my home town at St.Albans City Hospital (SACH) and was happy enough to go there. With a full social life and a lot of friends in the area, a nursing life on the doorstep of my childhood home suited me fine. There would be time enough later for moving further afield.

I started my nurse training in May 1983. Our group of 18 were partnered with a similar sized cohort who were based at my previous hospital the QEII Hospital. Our first and the third years would be spent at SACH and the second year at the QEII, whilst the partner cohort would spend their first and second years at the QEII and their middle year at SACH. Our group was all female, all Caucasian and all 18 years old bar two, another girl and myself. Both of us were just 19. We were a very typical nursing student group of the time, predominantly Caucasian, boys a rarity and English our first language. The age, cultural and academic diversity brought about by the NHS’s widening participation initiative was still some way off.

The class of 1983, I am back row 7 from the left!

On our first day we arrived as directed at the School of Nursing for our welcome talk. Most students were accompanied by either one or both of their parents. There were girls there from Somerset, Corby, Cambridgshire, Bedfordshire and Wales, each with a stack of luggage ready to move into the nurses’ home. Only I was without luggage because I lived so close to the hospital it was easier to move all my stuff straight into my room from home. I was glad in the end to have stayed in my home town, less adventurous than some perhaps but I had no home sickness or nerves to contend with either. I was already used to working shifts, I was familiar with hospital environments and routines and I couldn’t wait to have my own space away from home. Close enough to see all my friends, but far enough away to have some privacy.

Like most hospitals at the time, SACH had its own student accommodation (perhaps one reason nurse training was popular). This was housed in two ‘homes’; Church Crescent and Osyter Hills. We were given rooms in the Church Crescent Home, which was just a short walk from the hospital’s main site via the Folly Lane allotments (creepy in the dark). The Church Crescent site had been in use for medical purpose since 1887 when it was bought for £750 in-order to re-house the St.Albans and Mid-Herts Hospital and Dispensary which was then situated close to Holywell Hill, some short distance away. The new Hospital and Dispensary accommodation was built for just £3,750 with the aid of various donations, bequests and subscriptions.

 

The Oyster Hills Home at the top of Waverley Road was built originally on the land known as Oster Hills. Initially a privately owned eight bedroom family house sitting on the brow of a hill surrounded by orchards and paddocks, it then became a registered asylum in 1834, licensed to receive ‘no more than 15 lunatics at one time’. By 1851 the census records show it as family residence again, albeit lying alongside the St.Albans Workhouse which was built just down the hill on corner of Waverley Road and Normandy Road (then called Union Lane) in 1836-7. 

The Church Crescent, Oster Hills and Normandy Road sites were three parts of the four piece jigsaw that made up St.Albans City Hospital by the time I went there as a student nurse. The missing fourth piece originated as The Sisters’ Hospital, built by Sir John Blundell Maple and handed to the City in 1893 for ‘the benefit of the inhabitants of the city and the immediate neighborhood who might be suffering from infectious disease’.

 

The Maple Block, built by Sir John Blundell Maple

 
These four jigsaw pieces became one at some point and the resulting hospital a jumble of styles from the once grand house Oyster Hills House, to the sturdy red brick of the Church Crescent and Normandy Road buildings and the single storey ‘bungalow’ style infectious diseases ward, St.Stephens. More recently a multiple storey high rise building called the Moynihan Block was built to house the growing city population; it opened in 1970's (exact date proving elusive). The wards in the new block boasted a modern layout known as the ‘racetrack’. Unlike the traditional nightingale wards with beds arranged linear fashion down the length of each wall, the racetrack wards were shaped like a chunky number eight with beds arranged in 6 ‘bays’ of 4 beds each plus a number of individual side rooms. Sluice, linen store and treatment rooms were centrally located and therefore easily accessible from wherever the nurses were working. It sounds pretty standard now but in those days it was considered a very 'modern' build.

The Church Crescent nurses’ home was a two storey block with single rooms on each floor, shared bathroom areas and a communal kitchen on the ground floor. There was a television room downstairs and the only way to make or receive a call was to use the pay phone on the landing. Each room had a wash basin, a single bed and a small wardrobe, a chair and a chest of drawers. There was not a lot of room in the room but we could add our own things including a TV if wanted. My TV sat on a small table at the end of the bed and could be turned on and off with a carefully maneuvered snooker cue (I did not actually play snooker I hasten to add). There was of course no remote control. We brought our own kettles, saucepans, plates etc. and some girls even had small fridges. For the rest of us it was a question of leaving provisions in the communal fridge and hoping they would not be raided by someone else.

After being there a while I bought a Tower slow cooker and would sometimes make a casserole or minced beef, leaving the dish to cook slowly on my bedside table whilst I was on shift. I also perfected the art of cooking eggs in a boiling kettle (half-fill with cold water, flick switch and bring to boil, turn off straight away, leave for 5 minutes, remove and eat). When I eventually obtained a mini second-hand fridge, there was so little of nutritional value to put in it I hardly ever opened it. Also, I was smoking at this time (yes, I am suitably ashamed), usually packs of 10 John Player (10 because it was all I could afford and JPs because I misguidedly thought the black packet was cool). On one memorable occasion I lost my cigarette packet and a Mars bar having just bought them in a nearby shop in Folly Lane. I hunted high and low in the room then walked back up the hill searching the ground all the way and even asking in the shop to see if I had dropped them there. So rarely did I look in the fridge it was days before I thought to and found both Mars and cigarette packet nestling side beside in the otherwise empty fridge. I have to say my flirtation with smoking was relatively brief, my love of chocolate lasted decidedly longer.

 Next week: Getting started.. 

The case of the disappearing baby

Working as a nursing assistant on a paediatric ward 30 (long) years ago...

One baby I nursed on the ward was Iain. He suffered a brain trauma at birth which left him mentally and physically disabled. He required a lot of help with feeding and took a painfully long time to take his bottle; barely did he finish one feed than it would be time to start another. As Iain’s parents didn’t come often it usually fell to one of the ward staff to sit and coax him through each feed and whilst I had no aspirations to become a children’s nurse, I never minded landing this particular job; sitting quietly with Iain in his little side-room day, feeding and day-dreaming, the hours just sliding by from one meal to the next. Iain was with us for months and when I left he even 'came' to my leaving tea on the ward.

Another group of children who demanded a lot of emotional resource were the non- accidental injuries or ‘NAIs’. Periodically, a child would come in with unexplained bruising, a greenstick fracture of the forearm (twisted and snapped under a force such as when a child is swung around by the arm, for fun or in anger) or worse. Wherever intentional injury was suspected the social workers and police became involved and the child would be put under close observation. The procedures then were clearly focused on the child’s well-being and safety but the processes for ensuring these are much more rigorous now and suspicions more readily aroused. That aside, when a ten month old baby came in with a badly scalded bottom, the consultant paediatrician immediately suspected NAI. The little boy’s buttocks were bright red and the skin was blistered and raw; he cried constantly with the pain. His mother was from a traveler family who lived locally and she said she had accidently run the bath water too hot and his bottom had scalded as she sat him in the water. The consultant pointed out the perfectly round nature of the burn, the exact contour and size, he said, of a cooking ring on an electric hob, right down to the blistering concentric rings. He said it looked to him as though somebody had sat the baby straight on a hot hob and that, he said, was unlikely to have been an accident. The Mother looked sullen but did not deny it.  The baby's burn was dressed with paraffin gauze and he was given a strong analgesic for the pain. Eventually he settled with the help of some warm milk and was put in a cot in a side-room to rest.
 

At that time security in general hospitals was relatively low key and on the children’s ward the main concern was to prevent children leaving rather than to stop anyone coming in. Handles were placed high on the entrance doors to prevent any ambitious youngster reaching them and the doors were locked at night. Parents were allowed fairly free access particularly those of the very young or very sick children but other visitors were expected to adhere to the fixed times of the afternoon and evening visiting times. Parents of babies (usually the mother) often stayed overnight in the side-room on a z-bed, not very comfortable but it enabled them to be close by which was important for the well-being of both parent and child.

Several days later, as I sat on my supper break in the ground floor waiting area near the hospital shop, I noticed two members of this little baby’s family entering the ward. It was visiting time and there was a certain amount of movement in and out of the ward but I happened to notice the same two people leaving again not long afterward and remember thinking what a quick visit. When I returned to the ward shortly afterward it was to find that the baby had gone missing. I recalled that one of the baby’s visitors was carrying a blue hold-all and I realised with a sick feeling that I had watched them carry the baby out of the ward and right past where I was sitting. Security in those days may have been low key but the alert went out swiftly and the porters (who doubled as security) were out in the front car park in minutes. The family was just minutes away from driving off, the baby still in the zipped up hold-all but fortunately uninjured. He was put under a formal protection order and the family cautioned.

I often wonder what happened to that little boy. Nowadays of course access to paediatric wards is strictly controlled but what a field day the papers would have had with that one had they known………….

 Next week: At last, applying to be a student nurse

A back to front hospital, steam tents and gloopy feeds

After leaving Napsbury I went to work in the Queen Elizabeth II (QEII) district general hospital. The first full hospital to be built by the NHS, the QEII provided healthcare services to the people of Welwyn Garden City and the many villages in the wider surrounding area. The same villages also gave their names to the wards; Datchworth, Digswell, Codicote, Ashwell, Essendon, Knebworth and so on; from these I learned the village names of east Hertfordshire long before I ever knew where they actually were.

The hospital was 5 stories high and was ‘T’ shaped in design. The wards in the main building (the cross bar of the ‘T’) were organised into straight corridors with 4-bedded bays to one side and single rooms to the other. Half way along each ward there was a nurses’ ‘station’, a communal desk area where patient records were stored and the ward clerk manned the phone. The station was flanked on one side by a door to the clean sluice and on the other by a door to the dirty sluice. Commodes, bedpans and urinals were stored in the sluice areas along with the automatic bedpan washer. At the time we used paper bedpan covers to cover the contents of the bedpans and urinals when carrying them from patient to sluice. The covers were supposed to be thrown away prior to placing the bedpan or urinal in the washer, slamming the door shut and hitting the start button. Frequently though, the cover and several ‘disposable’ wash cloths would go in to the washer as well bringing things to a grinding halt more often than not. The engineers who had the unhappy job of repairing the machine (usually on a Sunday morning) were not best impressed by the nurses' continued failure to master the basic rules of using the machine properly. Not surprisingly, having the sluice right behind the nurses’ station also made for some unappealing smells and sights during shift handover or whilst talking to relatives, as well as an awful lot of noise when it was operating fully. 

Opposite the nurses’ station was the patients’ day room, a feature less well used in acute hospitals nowadays as patients who are well enough to watch television in a hospital day room are usually deemed well enough to do it in the comfort (or not) of their own homes. In the bed areas, each 4-bedded bay had large windows facing out toward a wide green lawn at the back of the hospital. The rear of the lawn was screened by tall, densely packed trees. In the misty early mornings, as the dark night hours receded, you could see rabbits and the occasional Mumjac deer nibbling at the grass, quite unfazed by the hospital’s close proximity. I thought this little touch of countryside was a thoughtful consideration of the hospital architects. However, not long after starting there I was told that the entire hospital had been built facing the wrong way round in which case the view was only ever intended for the sight of the x-ray and laboratory staff whose accommodation sat in the upright bar of the ‘T’. I never did find out if this accidental reversal was really the case but if it were it was a happy enough mistake.

After an induction period on an adult ward, I was put to work as a nursing assistant on the ground floor children’s (paediatric) ward. The layout on this ward differed to the adult wards in that it had side rooms either side of the ward corridor as you entered with just two bay areas beyond the mid-way nurses’ station. The ward walls were painted bright colours and curtains screening each bed were patterned with cartoon characters. We cared for very young babies (any baby not requiring neonatal intensive care) through to young teenagers aged 15 to 16. Side rooms tended to be reserved for the babies, the infectious or the very sick and it was in this part of the ward that I was often required. My main duties as a nursing assistant were to clean and set up equipment, make cups of tea for parents and help with feeds and feeding.

At that time (1982) hospitals were still providing nappies and feeds for babies. Nappies were the white toweling washable kind posing two problems, namely getting them on and getting them clean. Getting them on required a bit of a knack as well as an amenable baby, getting them clean required a trip to the sluice to get rid of any solid content and then a drop in the nappy bucket ready for laundering. These were large white plastic buckets with lids, two buckets to each room. Every day the buckets would be emptied and the nappies sent to the laundry for washing, the buckets would then be soaked in a chlorine solution, drained and dried for re-use. This was the responsibility of the nursing assistant on duty and basically required a lot of time in the sluice with smelly nappies and buckets. Another important part of the daily routine was the making of all the milk feeds for the babies. The nursery nurse would organise which feeds were needed and when. Working in the designated feed kitchen (known as the milk kitchen) we would start every day by cleaning the kitchen from top to bottom. We followed a strict cleaning routine which was followed to the letter every single day and included ensuring the bottles and teats were washed and sterilised ready for use, wiping all the surfaces with disinfectant and mopping the floor. After cleaning, the feeds were made up according to each baby’s requirements and each bottle labeled as to when it had been made, when it should be given and to whom it belonged. 

Whilst cleaning buckets, bottles and kitchens presented no problem to me, the making up of the milk feeds was a constant challenge. No one feed ever seemed to be the same. Depending on their illness babies might need a lower strength feed, a more concentrated feed, a small volume feed or most troublesome of all, a thickened feed. The babies who needed this latter type of feed would typically be those with palette abnormalities or severe gastric reflux; babies who either lacked control over their swallow or who could not keep the milk down. For these babies, the feed would be thickened by a gum based thickening agent and, if the baby had difficulty sucking, we would also enlarge the hole in the teat with a snip of the scissors. The thickening agent came in powder form and was added at the time of making the feed up by mixing it with boiled cooled water and milk powder to form a smooth paste (like making powdered custard). Then more boiled cooled water was added until the feed volume was correct. A notoriously temperamental agent (certainly in my hands anyway) the smooth paste would inevitably turn lumpy as the water was added and despite my best efforts, which included a small metal sieve and a lot of frantic bottle shaking, the feed would nearly always end up lumpy and unusable. I am happy to say my unsuitability for this task was quickly recognised and I was moved to other duties. Interestingly though, my custard making skills are unaffected.

The role of the nursing assistant on a children’s (paediatric) ward was less ‘hands on’ than that of a nursing assistant in a psychiatric ward for elderly women. The care then, as is now, was family focused and washing, feeding and entertaining was done wherever possible by the parent, particularly those with babies. With the qualified staff managing surgery lists (an endless round of circumcisions, tonsillectomies, inguinal hernia and pyloric stenosis repairs) carrying out complex care and administering medications, the nursing assistant was left to do all the various background jobs required to keep the ward running smoothly. Aside from cleaning nappy buckets, the nursing assistants stripped, washed and made-up countless cots and beds (the turn-around times in paediatrics often were and still are, very fast), carried out simple observations, fed any spare babies, doled out tea and sympathy where necessary, said goodbye to the better and hello to the poorly.

When children were admitted we would be told before-hand what they needed and this often involved setting up some kind of equipment. Monkey poles and steam tents were commonly called for. Monkey poles are metal poles that lock on to the base of the bed at the head end and arch over the patient’s head. A strap hangs down in front of the patient so that they can lift themselves higher up the bed or over to one side. For a young child with a broken leg in a plaster cast, the monkey pole allowed some freedom to shift position and to do muscle building exercises. The pole also allowed the more playful children to swing side to side when we weren’t looking which wasn’t particularly good for knitting together broken bones. The children on traction, weighted down by weights or water bags (to stretch limbs or re-position fractions) would lift, swing and twist in such imaginative ways, it was a surprise really that some of them ever healed.

The other piece of equipment commonly used was the steam tent. This was a metal framed tent with a plastic covering which was set up to enclose an infant cot. At the back of the bedstead hung a motorised chamber which was filled with ice. A big piece of plastic elephant tubing connected the chamber to the tent and when the motor was turned on the tent filled with a steam vapour which was intended to help the child breath. Used for children with croup it took a while to set up and had to be regularly topped up with ice from the ice-making machine in the kitchen. Sometimes there would be 3 or 4 children sitting in their tents steaming away, the steamer motor chuntering away in the back ground. Of course my description is reliant on a rather a long ago memory so the details are not necessarily replicable (or safe!).

 Next week: At last, applying to be a student nurse

My first death and an end of another sort

Despite that situation in the early days I settled and became very happy on Lilac. I learned a lot about people as well as the world of work in general, coping with shift patterns, early mornings, late nights and regular weekends. I saw my first death on the ward too, an elderly lady who died in her sleep and was found by the staff when the night shift handed over. I went with Eileen to lay the lady out, in what would now be considered the old fashioned way. We washed her, removed her false teeth and packed her rectum lightly with cotton wool to prevent any faecal leakage. Then she was wrapped in a cotton shroud, with a tiny frill at the neck. The sleeves of the shroud were secured with a bow at each wrist and her hair was combed out. A name bracelet was put first on one wrist and then on the opposite ankle; her big toes were tied together with a small cotton bandage before her ankles were secured with the same. The window closest to the bed was opened (to let her soul slip out, Eileen said) and then she was wrapped in white sheet from head to toe, the loose corners were taped into place and she taken away to the mortuary in a large rectangular metal box on wheels. I hadn't known the patient and there was no family that we knew of but we did our best to care for her respectfully and kindly even after her death. Sadly though, the health service has yet to find a way of transferring the deceased away from a ward in anything other than the rather obvious and eye catching metal box on wheels.

It's not clear what impact a death on a ward full of patients with severely impaired cognitive function has on the patient themselves but the death of a patient on any other ward leaves an inevitable ripple in its wake. Years later, as a Sister on an elderly care ward where deaths were not uncommon, we would sit and quietly explain what had happened to the other patients in the vicinity. It allowed patients to pay their respects and, if needed, raise issues or concerns of their own. Hopefully, we offered them some reassurance as well - that we respected and cared for the dead as much as for the living. It is important to recognise that the patient community on a ward experiences the same events that staff do but from a very different perspective; nurses need to pay attention to this in their actions and words. It doesn't always happen though, I have on occasions seen staff whip round the curtains at the site of the metal box and shoosh away the visitors without a word of explanation :(

Compared to my friends who had stayed on at school I had seen a very different side to life during my time at Napsbury and learned much that was to stand me in good stead in later years. However, I always knew that psychiatric nursing was not for me and when I was eighteen and a half I left Napsbury to work as a nursing assistant in a general hospital. At my leaving do, the duty Nursing Officer presented me with a beautifully wrapped parcel on behalf of the ward team. Everyone clapped as I opened it and much to my embarrassment out fell a black lacy bra and pants! Napsbury, was a truly one off place to work.

There were still other institutions like Napsbury Hospital in England in the 1980s, but the era of providing mental health care in such splendid isolation was drawing to a close. Public concern about the quality of care provided for sufferers of mental ill-health and physical disability in large scale institutions had increased over the years, fuelled by periodic allegations of poor care by the media. Politically, the long slow move towards providing an alternative option through the provision of care in the community started in the 1950s, driven primarily by humanitarian and cost considerations. But it took until 1990 to create the legislation that would enable the large scale changes required to take place. The first concrete steps toward change took place in 1988, on the publication of the Griffiths Report 'Community Care: Agenda for Action', which set out recommendations for determining the responsibility for providing care for long term dependents such as the elderly, the disabled and the mentally ill. This was followed in 1989 by the Government’s response in the form of a white paper called ‘Caring for People: Community Care in the next Decade and Beyond’. This paper endorsed the need to define the individual responsibilities of health and social agencies as well as identifying the need for ‘the development of needs assessment and care management’ and ‘a new funding structure’. The final steps in the move towards a national framework for care in the community, with the needs of individual patients at the heart of the health service structure and the funding set to stay with the patient, were taken on the enactment of the National Health Service and Community Care Act in 1990.

Napsbury at the end

Napsbury was really a unique and special place to work in but society had rightly recognised the need to care for its own in a more humane and more dignified environment and in 1998 it closed its doors for the last time having provided mental healthcare to the people of Hertfordshire and North London for almost a century. The experiences I had there and the people I met have had a huge impact on my life and my career and I thank them all (even the ghastly Jackie) for being such an important part of my formative nursing years.

Bullies - nothing new in the NHS

The first time I was bullied, I was about 6 years old and my tormentor was a girl called Rhona. She was a year or so older than me; she would wait for me at the school gate and when my Mum was safely out of the way, she would call me names, pull at my dress and push me in the back. I never knew why but I was a) chubby b) about the only child in the school who wore a uniform; apparently reasons enough to single me out as worthy of her attention. 

The second time I was bullied I was working at Napsbury and this time it came courtesy of a female member of staff called Jackie. Jackie worked upstairs on Lime ward and was good friends with Eileen the other nursing assistant in my team. She would come down to share a cigarette and a cup of tea with Eileen whenever they were on shift together. Jackie was not happy that I had the position on Lilac, she had hoped to transfer there herself. She was also not happy that Eileen had taken me under her wing since I had arrived. I of course knew none of this but Jackie made it very clear she did not like me, she would get up and walk away if I came to the table or turn her chair away and start a conversation with her back to me. What I didn't know was that she was also spreading some horrendous rumours about me behind my back . When I did eventually find out it explained an awful lot about the funny looks people gave me at times! For a while I was very unhappy at work but Jackie's behavior came to light eventually and I came to understand her unpleasantness was rooted in her jealousy of my friendship with Eileen. I was seventeen and a half and Jackie was in her forties and should have known better - I had much to learn about working with groups of women.  

 

Nowadays, there is much talk about bullying and harassment in the health service. Whether it be on a 1-1 basis, insititutional, top downward, peer, managerial, from relatives or patients (yes it happens that way too) or from colleagues, it is always wrong. The problem is that a bullying is a way of being, you can't switch it on and off and if you can't be kind (or at least respectful) to your work colleagues you will not be kind to your patients. I salute the Graham Pinks and Helene Donnellys of this world, who have spoken out about poor standards, harassment and bullying in the workplace, sadly, in both their cases, on a large scale. However, whether it be on a small scale or a grand scale it is never acceptable. It will ultimately always come back on the patient in one way or another, and for that reason alone it must be stamped out.

Next, the end of a (psychiatric) era...



Split back nighties, Buxton chairs and the 'Bath Book'

I stayed on Blackthorn Ward for a month before being moved to a permanent ward called Lilac, an elderly care ward with 26 long-term female patients. All the wards were named after plants or trees; Lavender, Beech, Ash etc. The one above us was Lime and it housed the male elderly care patients. Far more hands on care required was required in the elderly care wards than in Blackthorn so all the nurses wore uniform. The female state registered nurses (SRNs) wore white dresses, belts and shoes and the ward Sister, who also wore white, had a dark blue shoulder cape to distinguish her from the rest of the team. Male staff wore black trousers and white tunic tops. Napsbury had its own laundry where in addition to patient clothing, towels and bed sheets the staff uniforms were washed and pressed on site. Once a week we would collect our laundered uniforms from the laundry front desk where they were returned to us on an automated hanger system, beautifully ironed and carefully wrapped in a protective plastic bag just like a modern dry cleaners. 

All ward shifts were organised on a rolling rota, the simplest one I have ever worked on where weekends off could be worked out months in advance and ‘doing the off duty’ was a doddle. There were no rotational shifts, staff worked either day or night (although many worked additional shifts to earn extra money). The hospital ran its own bank nurse system and agency nurses were unheard of.  
The majority of the women on Lilac had lived their lives exclusively within the walls of the institution and what faculty they might have had was long since lost after years of hospital routine, limited stimulation and virtually no contact with the outside world. Some  were mobile, able to eat, drink and go to the toilet with relatively little help. However, most were dependent on the nurses for help with moving, washing and feeding. Some would punch and scratch you whilst being washed and others would lie rigid as stone. Sadly, conversations on Lilac were mostly limited to the absurd, repetitive or obsence. Sometimes the patient files gave some insight into what the women's lives had been like before coming to Napsbury which helped in understanding their attempts to communicate and occasionally a small photograph clipped to the folder edge would show a black and white, younger version of themselves, a glimpse into a life lived some 50-60 years before. 

To be in an institution like Napsbury for the best part of a life, with its locked doors, fixed routines and unchanging landscape, would be bound to bring difficulties. Institutionalism was inevitable and no less so for staff. Many people worked at Napsbury for years and had partners or children working there too; there was staff housing on site and a social club too. In many senses it was one big family and although the days of self-sufficiency had long gone, there was still a feeling of belonging to a very singular (somewhat exclusive) community as you drove through the entrance gates each day.
Looking back it is shocking to think how task driven we were but I didn’t know what I didn’t know and because patients were fed and clean and safe I never questioned whether we could do things a different way. In the mornings we washed patients in the dormitory with a screen placed around the bed area. Then we took patients into the day room. We had a few incontinent patients and they were dressed in dresses or nighties with a large slit down the back, so that the garment could be lifted aside as the patient was sat on a draw sheet tucked around a chair. Every two hours the patient would be stood or lifted and the draw sheet beneath changed if wet. They were then sat down again. Patients who were immobile might be sat in a tilt back Buxton chair to prevent them sliding down onto the floor. On Thursday and Friday we bathed all the patients and there was a large book in which we ticked off who had been 'done'. Patients were walked or wheeled to the old fashioned high ceiling, tiled bathroom with a big bath in the centre of the room and a (very antiquated) hoist to one side if needed. Two nurses bathed, one or two dried and dressed. Patients were back in the day room for supper at 6pm. It was horribly task orientated and completely lacking in dignity but in our (pathetic in retrospect) defense, patients were at least clean and pressure ulcers, even in the bed bound patients were unheard of.

Amazingly, we often had a sit down meal on a Friday night if all the work was done early enough. There were two particularly good cooks in our team; Romana, a Spanish nurse and Lily, a Filipino. I remember Romana cooking a wonderful Mediterranean casserole one Friday and her husband, one of the night nursing officers, coming to join us later in the evening when his rounds were done. Another time, Lily showed us how to make roast belly pork, cabbage and noodles, a dish I went on to make many times over the years (until being wholly overcome by vegetarianism). We would put together the tables in the day room, pull across a clean white sheet for a table cloth and sit down about 8pm when all the patients were settled. At seventeen and  a half I made my first ever Boeuf Bourguignon for my friends on Lilac, inspired by the continental creations of my older colleagues.

The patient food was less international in flavour. Breakfast was made on the ward; porridge or cereals and buttered bread. Other food was sent to the ward in covered metal trays to be plated in the small ward kitchen. Scrambled egg, bacon and black pudding were all regular fare in the morning. The ward domestic, Donna, doled out endless tea and coffee; after meals, mid-morning and mid-afternoon. As the youngest pair on the ward, she and I became good friends and not long after I left she also moved on, to train as a mental health nurse. As well as Donna, Lily and Romana, there was also Eileen, an older nursing assistant, who befriended me in the early days. It was Eileen who I worked most closely with; she showed me how to wash and dress the patients, how to feed those who couldn’t feed themselves and how to make beds quickly and tidily.

It was like having an extended family, and despite the heavy work I settled in quickly and felt very much part of the team. Strange then to think then, that Napsbury was the place where for the second time in my life I was to experience bullying. It is something we have heard much about in recent times as staff in the NHS have struggled to cope with increasing pressures and variable standards of care. Where staff have talked about feeling co-erced, harasssed and bullied to achieve the impossible with chronic staff shortages and diminishing resources. Thank goodness my own experience affected nobody but myself and certainly had no implications for the patients. 

I left secondary school in 1981, seventeen years old and unsure of what work I wanted to do. I wasn't old enough to work in a general hospital as a nursing assistant or to start nurse training and 'A' levels and University held no appeal for me (and as an average student at a  standard comprehensive school, nor was I encouraged to aim in that direction). Both my grandfathers had been milkmen in the days of the horse-pulled milk cart and I had a vague notion that I ought to follow in their footsteps so I enquired at the local dairy for a job but (fortunately in retropsect) I received no response. I also enquired at the Post Office because I was quite keen on the idea of sitting at a counter dolling out stamps and travel cheques and occasionally pulling down the 'Gone to Lunch' side in the face of an awkward customer. I don't think I mentioned this in my letter to them but they didn't reply all the same.

 

Then somebody told me that the '18 or older rule' for working in a general hospital didn't apply to psychiatric hospitals, so I turned my attention to another big employer in my area, Napsbury Psychiatric Hospital. To my delight they did answer my letter of enquiry and after a fairly laid back interview, I was appointed to work there as a full-time nursing assistant.

 

Napsbury was about 20 minutes from where I lived in St.Albans. It was one of a cluster of hospitals established between the 1860s and 1930s in the South of Hertfordshire to house the mentally ill of Middlesex and the surrounding area. Contemporary documents describe the hospitals (Napsbury, Shenley, Harperbury, Hill End and Leavesden) as providing care for those people of the district who were mentally defective, socially unacceptable, poor and neglected. During my time there, I saw the records of patients who had been admitted for conditions such as nervous indisposition, hysteria, fainting fits, insanity without reason and nymphomania. Several had been admitted with child and in disgrace.

 

Napsbury was built on the outskirts of St.Albans, close to the village of London Colney (now reputedly one of England’s largest villages). It was designed in ‘country estate’ style by architect Rowland Plumbe in 1900 and it’s easy to see how its spacious corridors, high ceilings and impressive breadth emulated the grand estates of earlier eras. The hospital stood in its own extensive grounds, large enough to grow food and keep animals as well as house various workshops and the staff residences. Although the farm was no longer working when I was there, some patients did still work in the gardens or carried out general maintenance jobs like collecting rubbish. There were lovely open green spaces with mature shrubbery and trees dotted around and whatever the weather, there would always be a patient or two standing around under the canopy of a spreading Horse Chestnut, masturbating al fresco.

Napsbury opened its doors to patients in 1905 as the Middlesex County Asylum. Originally designed to accommodate about 1200 patients, a further 600 beds were added only a few years later so presumably demand for beds was high. Over the years many patients and staff passed through its doors but by the time I went to work there in the early 1980s the trend for mental health services was already moving toward smaller care settings with much better integration into the local communities.

With six O’levels and just my experience of Cell Barnes to draw on I arrived on my first day of full-time work to be sent to Blackthorn, the admissions ward, for an induction period. Dressed in standard NHS beige (without injurious cap, badges or jewelery) I arrived on my first day in this most unfamiliar of environments. All the wards had open dormitories, bathroom, toilet, kitchen, linen storage and day room areas. Windows throughout the ward were big but with many cross bars so panes were relatively small, keeping window breakages to a minimum. Floors were tiled or laid with shiny linoleum and all the wards smelled; urine, faeces, sweat, saliva and food – all the base smells of human life. Doors were solid wood, painted with heavy gloss and paned with thick, wire-meshed glass. Entry doors were locked with a hefty metal key and if a patient went missing an immensely loud alarm rang out right across the hospital grounds. 

Most patients were housed in the open dormitory with each bed being fenced by a small wardrobe for personal effects. Personal effects were cleansed of all potentially dangerous items (combs, nail scissors, laces, belts etc.) on admission and were usually fairly minimal. Some patients had single rooms for closer observation or quiet and most wore their own clothes as did some staff, making it hard to know who was who sometimes.

Smoking was a feature of hospital life. Cigarettes were highly prized with many patients smoking the less expensive roll-ups. In the small shop at the hospital’s man entrance cigarettes were sold in singles so even the poorest of patients could get a smoke fairly easily. Patients would typically eke out their cigarettes until the very last shred of tobacco had burnt away. You could tell the hard-core smoker by the dark brown nicotine stains between their fingers. Any discarded butt would be quickly picked up by another patient and pulled apart just in case anything useful was left to re-roll. It was also common for both staff and patients to smoke, again making distinction between the two groups really quite difficult at times.

Patients were admitted to Blackthorn for observation before being discharged or being moved onto a more suitable ward. I was shown a strait jacket on my first day but whether for effect or not I was never sure, I never saw it used. Clinical management included a padded room which I did see used several times. Early on in my time on Blackthorn I also accompanied a patient who going for electro convulsive therapy (ECT).

With the patient on a trolley and me walking alongside we went with the porters down the long corridor to the ECT suite. The corridors were all long and wide with plenty of window light. The walls were tiled half-way up with highly glazed, chestnut brown tiles above which the walls and ceiling were painted a non-descript green/blue colour. Walls were often hung with pictures and paintings by patients. The occasional patient would be seen shuffling down the corridor, sometimes chatty or maybe on the scrounge for a cigarette, other times head down, eyes averted; nearly always alone. On one occasion I saw a male patient standing to one side of the corridor chewing earnestly on a mouthful of Maltesers, some of which had dropped to the floor. As I got nearer, a foul, faecal smell hit me and I realised the Maltesers were just balls of faeces which he was carefully rounding in his mouth then spitting out.

When we got to the ECT suite, I watched whilst the doctor sedated the patient and applied the electrodes, the patient was then strapped onto a raised narrow bed. There were other people in the room at the time and we were all asked to stand back before the treatment started. When the current was applied I saw the patient’s hair start to rise up and his body started to twitch. When it was over, we pushed the patient back to the ward and transferred him into bed to sleep. I found the whole experience quite disturbing but nobody said a word about it to me either before or afterward. In fact in all my time at Npasbury (which by the way I ended up loving) I don't think anybody ever talked to me about what we were doing there or why.

Next week, working on the female elderly care ward, with split back nighties, buxton chairs and little thought to privacy or dignity...

"But that is rolling dust Sister, we can't do anything about that"

Following on from last week...

On the gynaecology ward, where I worked as a Saturday morning domestic, the bed covers were pale pink, the bed wheels all faced the same direction (toward the middle of the ward) and the open end of each pillow case faced away from the door (yes, really).

The main ward was designed to the Nightingale layout with a separate and smaller ward area at one end for the convalescing patients. At this time, the early 1980’s, patients usually stayed in hospital to convalesce after their operation or period of illness. This resulted in a mixture of acutely ill and recovering patients on the ward, making for a very different ward dynamic to the one that exists in hospitals today. Staff had more time to get to know their patients and the patients had time to get a head start on the recovery process before going home to pick up work, domestic duties and family life again, as is often the case today. The mix of ill and recovering patients resulted in a different atmosphere to the ward as well; the convalescing patients would be able to chat to each-other, move around independently and even help with tea and coffee rounds if they wanted. The recovering patients often cheered up the sicker patients on the ward, giving them hope for their own recovery. For the nurses, the chance to work with the ‘convalescents’ was also a welcome break from the more stressful and demanding work with the acutely ill patients. 

As well as the mix of patient dependency, the number of patients having operations was fewer. The main operating days were weekdays with only emergency cases being handled on Saturdays and Sundays; this meant that weekends were quieter for everyone, with less acute activity on the ward and a generally more relaxed atmosphere all round. Later on, when I became a student nurse, weekends were to be looked forward to as a time to emotionally re-charge, a time to prepare both ourselves and the ward for the busy week ahead. Nowadays operating lists are no respecters of weekends, and Sundays can be as busy as Wednesdays whilst convalescence supposedly takes place after discharge, when life at home for the patient quickly resumes its normal pattern and demands. The rapid throughput of patients, if poorly managed, can impact negatively on their psychological and physical recovery with the potential for rapid re-admission for un-resolved issues such as wound healing and infection. Many patients in today’s National Health Service (NHS) would find it hard to imagine a time when post-operative patients stayed in hospital for several days or even longer after surgery or could go to a convalescence home near the sea to recover from their operation if they wished, as indeed some of ours did.

Peggy and I made a good team. She was funny and kind and despite our age difference we had a good laugh together. We also worked hard to keep the ward looking spick and span. I often think back to those times; goodness knows what the care on the ward was like but it was certainly very clean. Years later, as a ward sister myself in the mid-1990's, I watched the responsibility for ward cleaning being handed over to cleaning contractors and saw first-hand the loss of pride in cleaning that came with moving domestics out of the ward team. I'll never forget asking our ward domestic to clear the huge balls of dust behind the clinical waste bin in the sluice only to be told "But that is rolling dust Sister, we can't do anything about that" (!). On John D’Marinas, we were answerable to the ward sister and although she might not have known what to do with a cardiac defibrillator she certainly knew the importance of keeping the ward spotlessly clean.

 Next week, my first job as a nursing assistant in a pyschiatric hospital - what an eye opener for a 17 year old!