I knew what I wanted to do this right from leaving school. I wanted to be a nurse, and I wanted to work with older people. I had always had a great affinity with my grandmothers and older adults. I knew it was a Cinderella Service, but I felt prepared to meet the challenge. I did an A-level pre-health course at Stockport College. At eighteen I started my nurse training at Withington Hospital. As a newly qualified staff nurse I went to Barnes Hospital and did stroke care. I was fortunate, and became a ward sister within a short period of time here at Stockport. I hope my early appointment was attributed to my enthusiasm and drive to make a difference in this area of care.
I started my job as a ward sister at the same time as a newly appointed charge nurse. It was a good partnership. We had both been trained in the South Manchester at same school of nursing. The ward had both the benefit of a male and female perspective. Together we made changes – nurses were encouraged to owned the care they gave. We allocated specific nurses to specific people – it encouraged a deeper relationship – if you look after somebody day after day, you don’t just talk about the weather, you talk about real issues and what concerns them. Care needs to be personal and individual to give the greatest benefit. People think older peoples medicine is about incontinence and dementia. It’s not. It’s about adults who are ill – often with combinations of illness and complex care needs. We should adjust our ideas because people now stay well longer. We are more likely to give elderly care in all specialities of the healthcare. Care of the future cannot discriminate against age.
We offer dignity and respect, by discussing and offering patient’s options. It’s about control, offering choice, giving the patient control. Even as simple as: “ Do you want to wear this, or this?” At one time you did what the doctor ordered. Now, you get options, you are still an adult, not a lesser person because you’re elderly.
Older people have amazing life experiences. They’re an interesting group to work with. They saw the world when it was a different place. You can also ask the question: when are you old? A 65 year old can have an ‘older’ outlook than a 90 year old who is a fighter and has lasted through many changes in life. There was a lady I looked after who described how she used to chew the bed-sheets at night when she was a child, because she went to bed so hungry as a consequence of living in poverty with a very large family. How different times are now. Now we look after elderly people who carry mobile phones!
Even in my time of being a nurse, I’ve seen changes in care. If you were a patient with incontinence, you had to wear a pad and particular adapted clothing, almost a uniform. Pain management – now instead of injections, we have patches that absorb into the skin. We also have a more positive attitude towards death. With good management, you can have a good death experience, pain controlled, nausea managed, psychologically supported.
In elderly care, we assess for scales of depression, which can affect recovery – if you come in here thinking you’re going to die, it doesn’t help recovery. We discuss the need to use antidepressants if a low mood is identified. Lack of motivate hinders the recovery process. Treatment with antidepressants though may take two or three weeks to start a therapeutic effect and that can impact on the length of stay in hospital. The emphasis now is to get people out of the hospital as quickly as possible once they are medically fit.
The focus in rehabilitation has changed. It used to be non-acute care or convalescence in a hospital setting. Once rehabilitation patients were medically fit but frail and in need of therapy in a hospital setting. Now rehabilitation aims to happen out of hospital; in your own home, or in an intermediate placement at a residential home. Decisions about discharge destinations for rehabilitation are usually made considering night time safety and social circumstances. Hospitals are going to struggle with meeting care needs in the future as our population grows if it does not do things differently. Hospital stays aim to be about acute care, you come here if you are medically unwell and are in need of active medical intervention that cannot be met in the community.
Florence Nightingale said hospital should do you no harm. But if you put sick people together, you put them at risk. At home you are safer, if you can self-care. If people self-catheterise, they’re less likely to get infection. Same with self-care of emphysema, the emphasis now is training people to recognise they’re getting ill and to treat themselves with readily available steroids and antibiotics, so they don’t come into hospital and get recurrent infections. Kids with diabetes learn to monitor their own insulin levels.
Infection control is a big issue. We’re making advances in cleaning skin. Washing hands between patients, sterile gloves and aprons. There’s a lot of hand-washing. We wash hands before and after each person. But constantly hand-washing can make your hands dry and crack – which in turn carries risk of infection – so you need to moisturise hands too. Our hands are the tools of our trade so we have to look after them!
We use colour-coding: aprons are green for food, blue for dressings, yellow if a patient is infected, and white for general use. The mops and buckets are all colour-coded too to use in separate areas of the ward. Simple systems make a difference.
The public have been frightened by the news coverage of increasing numbers of MRSA and Clostridium Difficile in hospital settings. If you were to get on a bus full of everyday folk, a high percentage would have MRSA on their skin. That isn’t a problem as they are fit and well individuals. MRSA has a greater impact on un-well individuals especially those in hospital. Patients can become infected with the organism as a consequence of passing the skin barrier at wound dressing, catheterisation and cannulation and so hand washing and asepsis is vital practise.
Then there’s the bowel infection Clostridium Difficile, which is usually antibiotic induced. If you are frail and you’ve taken certain or multiple courses of antibiotics then you are susceptible to this infection. The antibiotics can destroy the good flora in your gut and the dormant toxin present in your gut can takeover giving you the drug induced colitis and subsequent diarrhoea which is clostridium difficile. This infection could then contribute further to increased frailty and an increased length of stay in hospital.
It’s about being human, coming into hospital. You are faced with your frailties. You’re the new kid at school again. You want someone to show you round, make you welcome. We’re preparing your journey, whatever it is. We have a duty of care and we try to engage family and friends too, for help. It’s not just about us who are the carers or experts in care. The family contribution is vital, as they know the particular person and how they behave when they are well. If they are concerned about something, I seek a medical review. They can’t necessarily say what is troubling them about the state of their relative, but they have a perception and it should be taken seriously, not dismissed because they aren’t professionals. Working together with the family unit is important to achieve the best outcome for the patient.
Complaints shouldn’t be dismissed either. They shouldn’t be seen in a negative light, because they help us to improve our service when we get it wrong. We are all human and capable of getting it wrong sometimes; as the saying goes “By the grace of God there go I”. If we don’t reflect, review and change, then we’ll make the same mistakes over and over again.
Who deals with hospital best? It is hard to say. Some people present well, but they will not share their experiences – they could be anxious or depressed. Men especially try to put on a brave face. You could line up five people with the same illness and they’d all present differently. It’s about how people deal with it, there’s not a right fix for everyone.
Accident and Emergency focus on illness first, but in rehabilitation we need to consider the physical, psychological, spiritual, social aspects. We determine how you were living before your illness, what are achievable goals, what goals are too big. People sometimes get disappointed if they measure themselves against others. But we are all different and can respond differently according to our life conditioning.
The physical and mental are interlocked. Some people believe that faith helps them. But you can also turn that on its head. Others see illness as a punishment from God.
Motivation and following instruction has a lot to do with recovery. I cared for a man who had a stroke, a bad one. By his motivation, his diligence, he recovered more than he ‘should’ have done. And the converse can happen. If a stroke damages part of the brain that affects understanding and you can’t follow instructions, then your recovery isn’t going to be as good. You also have people getting aggressive towards staff because of misunderstandings. If a nurse is doing something to you that you don’t understand, then you defend yourself. And that can get you labelled as difficult, or disturbed… If you have a diagnosis of dementia, people tend to stand back from you. But dementia doesn’t necessarily bring behaviour difficulties.
For staff, is it possible to have compassion, fatigue, burn-out? I’ve had burnout because I care passionately about what I do and understand my responsibility as a registered nurse and ward manager. I often stay after hours if the service requires it for a better patient outcome or to ensure management goals are met. But sometimes it does become expected that you will stay on and sometimes you have to draw a line that you balance your work and home life. Care can fluctuate at the end of shift, so you might stay on if you have the skills others haven’t. I’m the manager of the ward, so I need to have an overview of all the ward issues to lead effectively. I need support and good communication from the ward staff. I ask for feedback on their workload & how the shift was, to enable me to delegate appropriately & protect them from fatigue and risk of injury. I try to be fair & balanced with my decision making but I am mindful that we have to meet the service needs.
You’ve got to get a team that works well together – a 24 hour service. People cannot be left packed up in bed with incontinence pads. A pressure sore only takes a couple of hours to develop. You can’t sit and read or knit – you’re being paid to be a nurse. You are always on the go assessing, anticipating and meeting patients care needs.
If you’re a patient with dementia, you might need the prompt of sitting at a table with others in order to eat. People coming together makes them interact. People with dementia in that situation will perhaps pick up knives and forks when otherwise they might not have done if left to themselves. New wards are designed for bed to chair existence with no dayroom or dining facilities. This is the design for acute care and not rehabilitation. Almost like battery nursing on a conveyor belt- quick in quick out. Time will tell if this new design will change to again encourage patients to interact.
People need to understand their illness – for instance, a stroke is not a quick fix. They need a strategy, things to occupy them, to entertain them. Everyone is individual in this, recovery time is individual. And even their personal coping strategies have to change – using same coping strategy repeatedly doesn’t work. The family can help get people re-engaged into the community. Going out into the grounds in a wheelchair, go for a drive with your family. Achievable goals must be given to motivate recovery. Prognosis & progress should be discussed honestly. You have the right to the information first, if it’s about you.
We all become vulnerable at some time in our lives. This might be for physical, or mental, reasons. Or it might be emotional, a relationship break-up for instance. We hear a lot about ‘vulnerable adults’ and we have changed our practice because of that.
Changes always come, turning what we previously knew on its head. Nursing changes, it spirals, moving on. We should take the good with us, looking always with new eyes.
Interview with Philip Davenport, 2nd September 2009
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