Sat in the staff room a few days ago, I found myself talking to a consultant about how we love working in intensive care, and how we need time away from it to preserve our sanity. While talking I had a vague feeling of the jigsaw pieces not quite fitting together but I didn’t really grasp the significance of that feeling until a few hours later when we found ourselves at the bedside of a child who was doing their best to slip away from this world. My shift had ended, I should have been out the doors and on a tube home. But when a bed space looks like a bomb site you know there is still work to be done.
In a lull of activity, the same consultant said to me “this is what I’m talking about, this is what I love.” Suddenly, I saw the jammed-together jigsaw pieces and realised they were from different parts of the picture.
When the red lights are flashing and all the numbers are approaching zero, I feel sick. I’m shaking. My vision narrows to nothing but the trembling syringe in front of me and don’t ask me to calculate a drug dose. As a long term anxiety disorder head case, adrenaline rushes are not kind to me. This is not what I love.
So, let me confess it if you did not already know, I am a nurse. What I love about ICU is that it embodies the most cardinal quality of nursing. A few weeks ago, in a mentorship class, I raised the question of what we have to offer our patients that no else has because until we can define that, our entire profession is endangered. In danger of encroachment, of sidelining, of marginalisation, of being thoroughly demonised by a culpable government and a complicit media. To my disappointment, the majority of people in the class when they answered focused on the technical skills required of nurses. There is no doubt I am technically competent in many nursing tasks but so would you be if I trained you. Anyone can dress a wound or insert a catheter. That doesn’t make you a nurse and it certainly doesn’t make you the thing that your patient needs most in the world right here and now.
So what is it? What is the thing that I love, that makes nursing what it is? The secret comes, in fact, from the meaning of the word “midwife.” It means “with women.” The one thing I can give my patients that no doctor or physiotherapist or psychologist or any other of the team of experts can is simply to be with them. In ICU this is somewhat easier. I have my one or two patients for 12 hours at a stretch and there we are, all day or all night. Together.
I don’t crave the drama of saving a life. I am rather compelled to preserve the self, that has fallen into my hands, from the indignity of illness. Some would hypothesise that in the unconscious states often found in ICU, the self almost ceases to exist. Without consciousness, there is no you. You do not think, therefore you are not. I would hypothesise instead that the self of the critically ill individual simply migrates into the guardianship of those around them. Principally the family, but also the nurses. I keep your favourite toy next to you, I play your favourite music, I style your hair the way you always liked it, and I never let people see the bits of you that you wouldn’t want people to see, unless it’s absolutely necessary.
In the ultimate battle of life and death, medicine vs nursing, nursing always wins. There comes a time when doctors can do no more and they fade into the background and find a more interesting illness to beat. The Battle of Medicine, fought and lost over and over again. When it is over and they have moved on to the next diagnosis, there the nurses still are. Just being with you. When the drugs no longer work, I hold your hand, or the hands of your devastated parents. We talk, we laugh, we cry. We’re together. Because I have the time. Because that is what my time is for.
Unfortunately, in these straitened circumstances of cuts and a complete ideological re-evaluation of what the NHS is for, my time becomes more and more stretched. Dark times are upon us because we struggle just to hold our heads above water. Suddenly, I’m stretched to the point that all I can do is the technical. Just being with someone is not seen as a “good use of nursing time.” A sacrilegious notion to someone who believes that is in fact the best use of nursing time. And how much harder must it be on wards with 20 patients and just one nurse and one HCA/HCSW to care for them. It is not possible to care for so many people. You can give them their drugs and you can measure their blood pressure, but you’d have to be SuperNurse to create the time just to be with all of them. If all you did was spend half an hour with each person that is your whole day accounted for. It doesn’t leave much room for taking people to theatre and back, ward rounds, drug rounds and all the other bustle that makes up a day on the ward. It would certainly leave no room for the insulting nod to caring that is Intentional Hourly Rounding.
And somehow, Mr David Cameron believes a year spent as an HCA before nursing training will solve all this. Rather than seeing that running a healthcare institution like a business with more weight placed on balancing the books than on the safety and satisfaction of all the people within it – patients and staff – is making people suffer.
New nurses and nursing students are not at the root of the compassion fatigue that led to so many tragic and unnecessary deaths at Mid Staffordshire. In fact, the newly qualified tend to be refreshingly idealistic and intent on maintaining excellent standards. Then they turn up to work and discover that they have to swim against the tide of disillusionment, low morale, bad habits, bullying, poor leadership, cost saving initiatives, lack of staff, high sickness rates, disorganisation, hypocrisy, and everything else mentioned in the Francis report. The report whose only mention of student training is praise from a patient for a student who had time to just sit and talk with them. The report whose every other mention of training refers to the lack of staff training, the lack of time for staff training, the lack of a training culture, the old fashioned practices of medical and nursing staff.
Despite this, some still believe there is mileage in the “too posh to wash, too clever to care” sound bites. Well, maybe there is but not for the reasons you think. Let me go back to the entrusting of your self to my guardianship. As a nurse, with a degree, I understand that the skin is the largest organ of the human body, that it regulates immunity, temperature, sensation, excretion and that it is fundamentally linked to your body image and therefore your psychological well being So as an educated nurse, it is my duty to wash you. As a nurse entrusted with the guardianship of your self and your well being, it is my honour.
However, on some wards, washing is the menial task, assigned to those with lowest rank. Does your chief nurse wash anyone on Back to the Floor Fridays (if your institution is progressive enough to have such a thing – unfortunately mine isn’t)? I certainly hope so. Do the sisters? The charge nurses? The senior staff nurses? I am lucky enough to work on a ward with some senior staff who take pleasure in the privilege of washing the people they care for. I can’t say the same for other places. So can we really be surprised that people might object to being given a task which in the pervasive culture of that ward is seen as menial? Should we not rather be criticising the leaders of that culture for not pulling up their sleeves and just spending half an hour with their patients?
While we’re talking about leaders, how about asking for a little bit of honesty from our political leaders. It is time to accept that poor care is cause by, and I quote:
- Attitudes of patients and staff
- Target-driven priorities
- Disengagement from management
- Low staff morale
- Lack of openness
- Acceptance of poor standards of conduct
- Reliance on external assessments
(If you would like to discuss the meaning of any of these headings, please feel free to comment.)
And STOP blaming nurses, nursing students and nurse education/training. The most insightful comment I read in this report about nurses and the provision of nursing care was:
the constant strain of financial difficulties, staff cuts and
difficulties in delivering an acceptable standard of care took its toll on morale
You see that? If we, as nurses, are prevented by circumstances beyond our control from delivering an acceptable standard of care we suffer too. As much as it hurts and demeans our patients, it hurts us in some ways too. We are the ones who are unable to look ourselves in the eye at the end of a shift because all we had time for was the tasks, who feel hopeless and useless and that maybe we just don’t want to be nurses, or even human beings, anymore.
Ironically, all the time spent with our patients makes us the most visible, makes us the easiest target. If I ever find myself looking at the person I’m caring for and that irony comes to mind then I know it will be time to stop. Until then, I have the thing you need most in your darkest moments. I’m just here.The patient (or rather the person) should be at the centre of the NHS, that is what it is for. To see what people have to say about their experiences of healthcare, which is far more important than my experience of providing healthcare, have a look at such web sites as http://www.healthtalkonline.org/ and http://www.patientvoices.org.uk/