International Nurses Day May 12th 2022

 On the 12th May each year my timelines on social media, texts, and emails explode with greetings gladly shared between nurses and our colleagues in other roles. It’s the birthdate of Florence Nightingale so a fitting time to reflect. 

Today at Milton Keynes University Hospital we were encouraged to share highlights from our careers with other nurses, particularly those we may not know. This has led to many memories flooding back for me. Over 40 years qualified I’ve had many inspirational nurse colleagues, too many to identify individually, and fortunately only one or two that I’d rather not recall. So here’s a some lines to express my thoughts today.

Nursing life, and death,

have been my lot to be part of.

With love and fire, warmth and damper eyes

Each day remains its own. 

Nursing, my family, my tribe

Making differences for those around us.

Nursing, in times of conflict and in peace,

Demands sacrifice and lives, given without expectation of reply.

Nursing, leaves its mark and life long imprint 

The way to be, and always will be.

Too painful to laugh

It’s International Nurses Day 2020 and a motivation to digitally pen this piece. I find this COVID-19 time tough; it is tiring and has been something of an emotional experience. 

And that’s just the last week.

Whilst our team have worked hard with courage and resourcefulness, we’ve seen the impact on those dying and witnessed over the phone or via digital media the separation and sorrow on the part of loved ones.

I’ve wondered if I should scream at the sky, let the tears flow (wondering if they’d ever stop), simply wallow on the sofa (plus or minus alcohol) or find the words for a blog.

Apart from the poem below, tweeted about a week ago this will have to do.

Supporting each other has been critical; one of us is at home and able to work though stuck inside except the daily walk. I’m busy having daily interactions with others though each of those conversations has overtones of concern and uncertainty.

Then, personal loss struck through the death of a schooldays contemporary due to COVID. His family are bereft; and so many of us would like to be on hand to support and celebrate the life of Barry. 

And despite the jollity of VE Day and today being International Nurses Day it’s difficult to laugh and feel joyful.

And yet I am sustained today by the kindness of my team who staged an intervention today over their concern for me. Through social media there have been lots of messages broad and personal that have helped. Family members have been fabulous too. 

It’s good to celebrate the positives of nursing, where I’ve been home since 1978. 

I’m glad we can do this; and yet….

It is a painful time, and despite the rhetoric I’m not a hero. I’m simply doing a job I love. I suspect many of us will be reflecting on what it means to nurse, and to be bereaved at this time. 

I guess I could be accused of pouring cold water on this special day; it’s not what I intend. 2020 will remain a topic of discussion (for some); for others it may be just good to survive.

Thank you if you’ve got to here; I hope I’ve not been too negative. 

And I do look forward to laughing again soon.

Today, Was not just another day; A time when COVID anger and angst Brought so close pain and disbelief. And more pain, for those we’ve lost And those we’ve left alone. Tears don’t seem enough, For now they’ll have to do, Until we hold again. #COVID19. Written 5.5.20.

How will I shape the year of the nurse and midwife?

It’s New Year’s Day and I’ve seen a challenge to take up. Set by @BloggersNurse as we start the Year of the Nurse and Midwife I am planning on trying to write at least once or twice a month in 2020 on the themes suggested. 

January 1st and I’m thinking about how I will shape the year of the nurse (and midwife, please note I mean to be inclusive). 

It’s 41 years since I entered nurse training; my shape and that of nursing and midwifery have altered. Overall, the two professions have fared better shape-wise than me.

I trained to become a State Registered Nurse (SRN) in England, moving into a profession held in high regard. 

There’s been the transition to degree based learning, and recently apprenticeship programs. All routes opening to a career of varied opportunity. 

What shaping influence can I have? The immediate one as a senior and experienced nurse is as an example of being open, kind and flexible. 

I have to be open about how I work, and be prepared to let others lead where they have ideas and strengths that I don’t possess. Be ready to adapt and adopt fresh thinking and take risks to make gains in service improvement.

I want to be kind and even kinder, to all those in my care. This will be patients as well as my team colleagues, and those in the wider care community in which I work and have a social media presence. In particular it’s those who are exploring the possibility of nursing as a career, or already in training, to whom I should be an example. Showing enjoyment and enthusiasm for our work, and giving such people time will help them be great nurses of the future.

I need to be flexible; my career has had twists and turns; some hoped for and some unexpected. This has helped me appreciate the opportunity of being ready to try something new; to allow me to be trusted by people such as team members when they require some wriggle room - flexible working to allow for family issues for example.

Applying this to shaping the year of Nurse and Midwife? 

Being an example, supporting those I come into contact with and reaching out through social media. 

Embracing and getting involved in events to celebrate nursing, and show the value of nursing work to those who question what nursing is.

Supporting those I work with to look at what we do, and see how the work can be done differently. Getting them to speak up, in person, in blogs and engage in further education so they can be shaping too.

Change happens; being prepared to influence the outcome is a way I can contribute to the year of the nurse and midwife in 2020 and beyond.

Be brave, honest, open

Inspired to write today by a blog from Tony Warne (an impressively regular writer) I wanted to reflect on the report from the BBC about the lack of cultural competency in hospices. Based on research conducted by LOROS Hospice and Leicestershire Hospitals I wasn’t surprised (sadly) by the findings and the call to action.

I’m aware that many hospices have been trying to engage with those in their surrounding communities. Offering the opportunity to share information about services, and to learn more about the perceptions their neighbours have about hospices.

We now have a greater understanding of the importance of being able to talk about death and dying, and the difficulties nurses, doctors and others involved in caring for those who’re dying face. How important is it that we reframe hospice and Palliative Care services? In my professional lifetime many cancers have become more of a long term condition though still with notable exceptions such as pancreatic cancer. The focus has shifted to supporting those with longer term conditions to get the best out of their situation as they can. Hospices can, and do, help with that.

Perhaps hospices should move to being a community health hub, where services reach out into people’s homes and tackle loneliness, poor physical environmental conditions, encourage finding ways to improve individual’s health and bringing forward the conversations about death and dying.

As cultural norms shift we have to recognise that some changes have left us afraid to address these issues. Time to be brave, be honest and be open; a call to all who believe that being open about living before dying is important to all those around us.

The little big things

As I've begun my new role as a lead Nurse  for Palliative and end of life care I've been reflecting on a whole host of things and it's only week two.
The last couple of days have though reignited the importance of the little things we can do when we meet patients.
So,
• opening a bottle of beer courtesy of a passing physiotherapist and his key ring and witnessing the enjoyment of the person who was waiting thirstily
• admiring the sand dollar earrings of an older woman that led to a chat about the USA
• Witnessing the team effort that led to a quietly dignified wedding this afternoon, organized this morning that took place in the room in the photo - everyone lending a hand for an event that always leaves me with moist eyes.
Some were efforts were smaller than others; for me the key is to recognise any opportunity to take action in some way. That way is positively helpful to others as well as being satisfying for me at the end of the day even though it was difficult to turn down the offer of a beer.

Feelings of an ad hoc carer and frustrated professional

Just now I'm aware my mum is undergoing a endoscopy and I'm at home after spending a few days with her. In my earlier post about the NHS in November 2017 I laid out my views of what we were experiencing.  
Now it's time for an update and perhaps less positive reading.
After discharge from a 3 week stay in a rehabilitation bed the Friday before Christmas mum was experiencing trouble with reflux from what we eventually discovered (in a post Christmas telephone call with a GP) was a sliding hiatus hernia. This was known about in hospital yet no mention of it was ever made.
Mum has gradually regained her mobility and with support from the family and neighbours was managing just about at home. 
The big problem has been to get anyone to take her painful regurgitation and reflux seriously, along with her weight loss. For a serious cook like mum, who enjoyed a varied diet and particularly going out to eat the reduction in appetite and feelings of hunger have been a depressing downward spiral with no sign of improvement. 
The oral medicines prescribed to improve the situation were having no chance to work.
We've tried all sorts of things; bed head end elevated, mum using the internet to make sure she was using NHS advice for her diet and the variety of medication that was promised to make a difference.
Only this week have we got a GP to call round; the vomiting of almost every fluid and food mum has tried to take was largely ignored because its all 'infection'. Mum has lost half a stone in recent weeks and we believed we were approaching a crisis point that could surely have been anticipated with better community support. The community nurses who visited shortly after discharge told mum they'd keep an eye on her; though hearing impaired mum got the (correct) impression she'd not see them again. 
The senior GP who mum got through to thought she was calling her rehab place; we'd made it clear to the surgery that mum was home...
So between family members and her marvelous neighbours we've tried to find attractive foods and fluids; my catering experience helped here though only marginally.
This week, having been forced to take a frail and low energy mum to the local hospital for a blood test we reached crisis point. The 111 doctor called to say her bloods deranged and needs to go to hospital. So mum is now back in hospital and having her endoscopy. We'd considered getting a private consultation to see if we could get someone to take notice. 
For us, and my experience in the last week this seems unnecessary; felt like trying to keep mum out of hospital (understandable in some way given recent news) though at the expense of ambulance crews and long (overnight) waits in A & E. And we had more than one nurse advocate trying to get help for her. 
Where is the multi professional review and support for older people in the community?
Were mum without family and her support network I dread to think what would have happened. 
It's frustrating and we have some inside knowledge that you would expect to help get us further; it's frightening too.
Right now I have to trust my hospital colleagues and keep faith in the system overall; for Mum and as so many other carers have to do day after day.
As I finishing writing this mum's GP surgery have called me - they're trying to get hold of mum and wondered where she was - her blood results need rechecking... they are surprised (and relieved) she's already in hospital... where's the communication? 

Learning through Social media

I’m participating in the #AllOurHealth course set up via Public Health England (PHE) and WeCommunities through @WeLearn_.  I decided to join Wave 1 which concentrates on the introduction to Twitter and other social media and its uses in Continuing Professional Development (CPD) for healthcare professionals. Having some experience of Twitter use for a few years I wondered if I was going to find the first level uninformative. In the meanwhile I’ve moved from my hospice role with a view to changing to alternative activity and am preparing to revalidate via the NMC. CPD is therefore uppermost on my mind. 

I’ve been finding the course really helpful; it’s prompted me to rethink my attitude towards the usefulness of social media and Twitter in particular.b In my course reflections I’ve been recording how I need to be rather more disciplined and focused about using Twitter for CPD. I’ve set myself some professional goals using the tools on the #WeCommunities website as well as personal goals that I’ll have to work on myself. 

Meanwhile the #AllOurHealth participants, waves 1 and 2 start on Monday by looking at social media use in promoting good health and the prevent of illness. Lots of great resources have been developed for us to use, and indeed many are already publicly available via Viv Bennett in her blog piece about the AllOurHealth program.

And if you’re wondering about the value of social media and online training for CPD, please give them serious consideration; my experience so far has been a positive revelation, thanks to all those involved in putting the course together. 

The NHS as I see it just now

This feels a little tough to write; my lovely energetic mum has acquired a chest infection that's making her very ill so she's now in hospital with the NHS team doing its best to help her. We've visited  three clinical areas after A and E, and at the time of writing mum is in the ITU having supportive ventilation. 
An impressive array of clinical staff have been involved in delivering her direct care supported by a larger army of support workers and those whom we'll never see. 
My observations -

• #HelloMyNamesIs has not penetrated everywhere yet which feels disappointing though there have been many who have introduced themselves and wanted to know and use our family's names
• Car parking fees are crippling unless you're eligible for a special deal so ITU admission will save us money (mercenary on my part I know, and I wonder how those with lower incomes manage)
• There's a great focus on finding out about the person needing care and including us in conversations about options for care such a DNACPR
• All this work is being supported by people who are from around the world as well as those locals who are living down the road having been born in the same hospital 
• Limitations on immigration (and the current drop in nursing numbers linked to Brexit) will have dramatic impact in the near future 
• Outsourcing to private companies is increasing; depriving trainee GPs of pay for example; ward cleaning and catering have gone the same way and only personal teamwork based relationships ensure smooth working
• Busy staff can seem uninterested however we don't know how long they been at work that day nor what they have had to deal with so far 
• Cooperation with the caring team helps even in the times of uncertainty
• The gift of a cup of tea or coffee is a sign of caring for individuals and is much appreciated; however if providing tea and coffee making facilities please make it easy to find cups and water for the kettle; we're happy to do the rest
• The estate is often old and can look rough; even so I saw signs that reuse, refurbishment and rebuilding is going on. That said toilets out of use for some days because the drains are blocked is not good and symptomatic of the privatisation relationships 
• A and E queues for ambulance teams are so wasteful of all those resources; let's put money into getting people home and supporting them there
• Link the technology; observations made on one ward and recorded via the handheld device cannot be seen on another ward (?) after transfer. Hand written notes mean we have to repeat the stories
• Please be prepared to repeat instructions to dazed and anxious visitors like the cheerful security desk lady did
• Nursing - so much technological expertise required and this needs mixing with empathy and genuine communication; that combination will win the trust of the person in your care as well as their loved ones

Overall I've been deeply impressed with the dedication and commitment of those we've come across; the NHS is an institution that comes in for criticism too easily too often and what I've seen today shows a multi-faceted, multi-talented, multi-national workforce freely available to do their best for those in need. This is to be applauded and protected; it is something that our family is immensely grateful for.

Times for tears

I have recently wondered if had been developing hay fever; I've had ‘leaky eyes’ and perhaps a few sniffles at various times. I'm pretty sure though that there have been times when I've shed tears. As family will tell you simple things on tv will set me off; dare I say it extreme reactions to great acts on Britain’s Got Talent is an example.

At other times though other things have acted to set me off. Frustration at my own actions; delight in others successes; hearing inspirational stories and hearing news of those who have died.
After a busy time at work and recent terrorist acts in the U.K. I found myself suddenly anxious too. This caused me to reflect on what life was like at the heart of the Irish ‘troubles’ when I spent lots more time in central London. As I write I feel much less troubled about risks particularly as I commute by car each day.

What sparks the tears though? As I've reflected on my career in recent times I've recalled times of sorrow and delight. I've said before that my passion is about getting end of life care right for those who are dying. I've also said that in the position I'm in now means I have many people that I care for in our organisation. My actions can have ramifications that are unexpected; to get it wrong as I've owned I might do before, is frustrating though it becomes a vital learning experience. 
A contrast to this is seeing the investment in others resulting in their development; finding ways to study and change their lives as well as simply passing on messages of a thanks for a job well done is another cause for celebration. Yes, a potentially tear jerking time.

Obituaries of people who've been in the public eye, such as Peter Sallis who had entertained me for so long can induce a weepy episode, particularly when set alongside the news of multiple killings on Manchester and London streets. One person I recalled was Lawrence S. Newcombe who died in 1987 (with 30 others) helping another person in the King’s Cross fire; he trained as a nurse at the same hospital as me and I recall him as a force of nature.

My joy at the achievements of others has been filled today as one son, who is proudly part of the NHS has passed his training course and now has heard he has a job in the department he works in. Lastly however the inspirational story telling by people such as Tommy Whitelaw provokes my lacrimal ducts; he reminds me of the importance of knowing something of the person I'm with and finding out about their story. Being able to share our emotional reaction with those around us is powerful and emphasises our joint humanity. Allowing times for tears is as useful as sharing laughter; for me it's important we're open about this too. 

Heart Head Kindness and other influences

Tweeting away a couple of days ago I came across @WeNurses #nursestaketen  which encourages us to do something a little different, even if just for a short time. It made me seek my take ten moment, and as winter approaches I'll return to some creative activities in the darker evenings. The suggestions also included writing a blog from the heart; a prompt if ever I saw one as my heart has been a cause for concern in the last couple of weeks though thankfully the local rapid access cardiac team tell me I'm ok. My emotional heart has been touched by reminders to be kind to ourselves in David Gilbert's blog and being kind to others in Dr Dharmaraj Karthikesan's blog.

All very well beng chilled about kindness;  then I saw references to poor care home standards in the news; in particular what was evidence of an indefensible nursing attitude. The news piece flags up stereotypes of Care homes; whilst there are obviously concerns about the home mentioned it ignores the many excellent and simply good care home there are who can make a difference. 

It was the quoted, secretly filmed words of the nurse that struck home to my nursing heart and head. Immediate  to be "struck off" thoughts were the initial reaction; the attitude that allows uncritical use of medication for care givers convenience is wrong. But head says how did that person get to that place? Are they so isolated, denied training, supervision and support that they have lost that critical internal voice that says - "stop, think a moment" before you speak and act? I understand from the report the nurse has been suspended; I presume some disciplinary action will follow. 

Both heart and head say who was being kind to this nurse and their colleagues? Who was listening if they raised concerns? I suspect no one was. How can we reach out to our colleagues who find themselves in such conditions that they cannot "take ten"; maybe the act of kindness in seeking other professionals working in isolation and offering to share a coffee, tea and cake (nurses know the value of cake) and allowing them to take a break will avoid this kind of headline being repeated.

I realise I'm fortunate in being able to reflect on this from afar; I hope nursing and others will take heed of the calls for kindness not just to others but to ourselves; if we cannot do that our responses to those in distress, in need of kindness, will find no use of head and no gift of heart in those who are expected to care for them. 

A challenge or piece of cake? Being person centred in a hospice environment.

 The opportunity to begin the introduction of looking at how person centred our practices is at St Clare Hospice is too good to miss. Starting with the use of my one page profile #Onepp (1PP) as I began my current role I wanted to expose my new colleagues to what is a different way of thinking about care. 

Why bother when we could say we practice the best holistic care with all our patients? 

I am concerned that holistic care is a blanket term for care structures and processes that are uniform. The care cannot be person centred if the same care model is used in the same way for all. Being person centred is about making what is important to the person central to planning and organisingtheir end of life care, and crucially the person concerned is involved in the preparation. So whilst taking the same approach to care planning the result is individualised care that is set up around what works and what does not for each person. 

In the following stage I have begun work with the inpatient unit team to review just how person centred the unit practice is. We are using the Progress for Providers – End of Life tool from Helen Sanderson Associates to see how person centered our current practice is. This is available electronically too. The group are meeting and working through the tool; I am letting them take the lead so they are ready to own the action plan and next stage of work. 

At the same time I’m seeking support from senior managers and our Board to make sure they understand what we are doing. Once we have completed the assessment stage we can use the tool to create the action plans and priorities for action. The intention is to spread the use of the tool across all our services at St Clare Hospice as we take on an increasingly person centered approach.

I find this an exciting time as teams look afresh at what they do and how they perceive the care they give. I believe it will help us see the relationship we have with those who use our services in a new light as we focus on the person who needs support towards the end of their life. I look forward to telling you more as we progress. And at that point I hope we will be ready to face any challenge, and being a hospice be armed to face it with plenty of cake.

Philip Ball

Director of Patient Care, St Clare Hospice, Hastingwood, Essex.

Being a target

Those who follow my tweets and those who access my Facebook page might have seen my posting about my health incident this last weekend. Enjoying a 'self-care' stay at a hotel near mum's prior to the UK Mothers Day, I became unwell during dinner, experiencing severe abdominal pain and feeling feint. Within a few minutes the kind and helpful hotel staff along with Megan decided help was required. The London Ambulance Service crew showed up a few minutes later and took control of the situation. I remained conscious and with my first aid and nursing knowledge realised the possibility of either an aneurysm or heart attack were high on their list of concerns. Dodgy food was  considered though no evidence was seen.

I was soon in the ambulance and wired up to the ECG machine, whilst the crew calmly went about checking me over. Without further discussion we set off for the nearest A & E where after a few minutes wait I was loaded onto a trolley. At this point I'm sure the ambulance reached me inside 8 minutes, and I was dealt with efficiently so the crew were on their way after handover.
It was relatively early on in the Saturday evening so the staff were fresh and not under too much pressure; my vital signs were recorded by a RN who used hello my name is, nice! A cannula was put in my arm and bloods taken; Megan was asking if there'd been anyone in the lab to process them. I was sure there was; some things have changed a lot and I expect there was machinery close by for doing the analysis required; there has to be to aid meeting targets.

I was put into a single room and vitals checked again; different RN and no ' hello my name is ...'. A cheerfully helpful HCA recorded another ECG, and gave me a gown and blanket with an apology for the lack of a pillow. He was another 'hello my names is ...' hero along with the doctor who saw me. The HCA insisted I put the gown on (I kept my trousers and shoes on all through my stay) though I'd have preferred to stay in my T shirt; a curious requirement and no reason from my perspective. Does wearing the gown help differentiate me from visitors and make life easier for staff? Is this a money saving opportunity missed? On a similar point why not have universal ECG stickers so the ambulance ones aren't pulled off and new ones applied at hospital?

My main question I suppose is around the need to transfer me without question to A & E? Would a wait a little longer at the hotel have reassured all concerned it was a one off and that resting in the room would have been ok? Maybe with my insight I would have been ready to take the risk that it was a one off episode and did not need hospital intervention. I suspect though that algorithms and risk averse targets played a part in driving my care rather then patient choice and perhaps an application of experience and common sense.

Treated with warm politeness at the hospital, privacy and dignity were only nearly there. Wearing a gown as one carried a sterile pot to the toilet clearly shouted - "he's a patient off to do his urine sample" - amplified by the evidence visible in my hands on the return journey did dent both privacy and dignity. As a nurse its ok to walk about carrying other people's bodily fluids; as a individual carrying ones own, its a whole different situation. Within about 3.5 hours I was allowed out after some IV fluids and pain killers, clutching my blood results sheet - though not sure why I was given it. We dutifully completed the Friends and family test card. So, I was treated and moved on from A & E inside the 4 hours and the ambulance team did their job too in that regard; I was a target met.

Was I safe, cared for effectively, in a responsive manner by a well-led team? Yes, so CQC-wise I have no faults to mention. I am still left questioning whether the expense of resources for me was a good use of what was available that evening. I asked the senior nurse who helped administer my IV medicines about the coming shift; it was clear that my case was a straight forward one; single episode of nasty tummy pain that passed off quickly and simply. Yet to come for the ambulance and A &E teams was an after midnight rush of drunken fighters and fallers, that required an increasing police presence. That makes those public servants targets of a different kind, and a group of people for whom I have the greatest admiration.

A man of letters, all about E's and the 7th C

Enthusiasm - our younger cat has a way of launching herself at the world each day as the dawn chorus starts without hesitation and a tangible sense of purpose. How many days do we start like that?
Engagement - on the 12th May #IND2014 I was able to join my Twitter friend Pam Nelmes and the lovely team at Plymouth University School of Nursing and Midwifery to witness the finals of the 4th annual Nursing and Midwifery Challenge. This was a great day seeing how nurses and midwives of the future can engage through their learning and experiences on placements to create innovations. It was motivating to see; a positive sign for the future, and I strongly advise you to to keep a look out for the winning idea. 
Enterprising - All this is of course very enterprising; I know our hospice team enjoy the challenge of finding person-centred ways to deliver care to those in our hospice. The team thrive on discovering ways to raise and save money to support our work. Their enterprising nature is taking our service forward.
Employment - this is more personal; as I write the organisational  announcement is expected regarding the outcome of the reorganisation process going on at my level that began in late March 2014. I and my peers have had our current posts 'deleted' (technological language providing cover for harsher words - a whole other subject?) and an interview process for the new posts has taken place.
I have been unsuccessful. 
I know now, for the first time in my experience,  that redundancy is a realistic proposition. 
I readily acknowledge that I am not unique in this; I am not complaining, merely letting you know. I would like to make plain my thanks to all those who have offered words of support and commiseration. My peers in the same situation as me and the hospice leaders I met at the end of last week have been very kind; my family have stepped up too with their messages.
The Challenge is to keep going; there's no immediate threat to my income as there is plenty to get done. I suggest though that for me Challenge is the 7th C (see the 6Cs here). It is almost unnecessary to say its a time of opportunity too.
As so often happens though timing is all. I have joined the discussion on compassion and resilience stimulated through the blog by Maxine Craig. Then along came a blog by Laura Green, about the nature of resilience, and in particular its dynamic state, within the setting of end of life and palliative care. All in all very helpful and enabling me to keep my head. 
So now I face new opportunities; I'll need my enthusiasm; I must find ways of sustaining my engagement and use enterprise to identify what next in terms of employment.  I think that's enough challenges for this Monday morning.

Making a difference - being creative with the environment and your care

Today was scheduled to be a day off; possibly a lie-in then potter about. The news the night before of a older relative having had a stroke a couple of days before led to a busman's holiday drive across southern England to see them. Before leaving I was able to read the leaflet about the relevant stroke unit, and find details about the car parking charges; a plus mark of the internet.
So we set off  and in good time arrived at the hospital though 20 min early. We were ushered to the Day Room - visiting time had not started. Of course this set me thinking, the @wenurses tweetchat had discussed visiting times the previous evening; follow the link to read more, including the pre-chat information from @wlasinclair .

We complied with the request to wait and so entered a room that looked like this in one corner -

the opposite corner housed a large TV playing to no-one.

Not a great first impression and certainly not  a safe patient friendly space; nor welcoming for visitors. The label inevitably said 'broken'; I wondered how long it had been there.

There was no easily readable information for visitors, i.e. a map to show the location of the toilets, tell us where the cafe was and so on.
This notice board was inaccessible.

Inside the door was this notice - 

all nicely ironic and the poor grammar seems to indicate we're all Sisters now.

Once we were at the appointed kick-off time we ventured to the Reception desk, and it took a few minutes for us to be asked 'are you OK?' This despite a plethora of staff around the central station; none had easily readable badges. I just had to go on who was wearing fob watches or stethoscopes; a staff nurse did help and showed us where our relative was.
Of course we were limited to two visitors at a time; within minutes though this became problematic when their friends arrived; this is after all a very sociable person who enjoys a good party even though they're 90 plus! I suppose I wouldn't mind the limited visiting and two relatives at a time if the rationale was clearly explained in the literature, by diagrams or by someone tasked with ensuring visitors knew the 'house rules'.
Getting to the bedside we were able to begin to chatting and having taken my drawing pad, we made progress with communication. Of course were relieved to see our person dressed and sitting up; there were a selection of leaflets for them to read - left out of reach on the bed. A nurse on duty for the afternoon passed the #hellomynameis... (thanks to @GrangerKate for this idea) test; as did the speech and language therapist.
Here we were shown the three side of A4 that had been left earlier asking questions about our relative; the SALT team wanted to know more about them. 
Oh how I wished I could have shown them a one page profile; we had fun however altogether completing the form, though were left wondering how widely it would be shared. I hope it will be; there has been a lot of life lived by our relative, around the world. The developing #facetoaname idea would help here too.
During the visiting hiatus caused by the physios - (why restrict visiting?) I had a look at a notice board that showed safety data graphs from a year ago; a 'You said ... We did' poster that was blank and some quotes with codes numbers that were meant to be patient and visitor feedback. Opposite at a drunken angle as its Blu Tac was wearing out was a certificate from 2009 given to the ward team from the hospital management team.
l must acknowledge my bias and perhaps more detailed knowledge than the usual visitor; none-the-less what appeared to be a well staffed ward was not looking at the details. At least not always the right ones; whilst we went back to the Day Room during the physio session, a tidy soul put away our visitors chairs: we had to retrieve them. 
I would ask, and I think I will have to pass on this feedback to the ward, that someone looks again at how you present yourselves as a team, your environment, and demonstrating newer ways of working. 
For a lively mind now hopefully only temporarily caged by impaired speech a one page profile would make a difference; give them a relief from the frustrations of their situation as others can share their life. In looking at the ward environment I hope the ward team can demonstrate how their commitment, courage, care, competence, compassion and communication makes a difference to those they are looking after.

Reflections and Echoes

I have been considering writing again for a while; I suppose this is a kind of 'slow-blog' or 'Slog'.  As ever though, strands of life have combined to make sitting down to this task inevitable. I have a notebook that since given it last Christmas I have used to jot down thoughts and ideas. I can see that in mid-MArch 2013 I was thinking about creativity in nursing.

In response to comments by Prof Don Berwick reported on the BBC on 12/3/13 regarding Mid Staffs I was asking do we stifle creativity in healthcare and particularly in Nursing?
Whilst pondering that on 14/3/13 Roy Lilley said this in the first of his blog pieces that day,

"Nursing has been at the forefront of innovation and nurses use some of the most sophisticated kit the NHS has to offer.... Nurses are the mothers and daughters of invention."
So I am not missing a theme here; once we consider nursing history we find the examples of Florence Nightingale, Mary Seacole and many others who have developed kit and service models since then that have led to improvements in care. In my specialist field of palliative care Dame Cicely Saunders qualified as a nurse, as well as in medicine and social work. Her influence remains profound though I wonder if we have lost some of the energy that went with such creative spirits. Is working under the pressures many nurses describe sapping their energy and ability to see problems as they occur?

The other requisite for creativity is risk taking; when dealing with the lives of others we obviously have to minimise the risks, 'do no harm'. Yet whilst discussing service improvements via a Twitter nurse chat last week, care of WeNurses it was evident there were plenty of ideas yet little evidence that things were easy to change. So if creativity is there, what seems to holding things back? Is the appetite for change difficult to identify amongst the bad taste in nursing's mouth delivered by the hands of the detractors of the NHS? 

In all of this I had decided I ought to try something different in terms of learning. I took advantage of an offer from Martin Shovel to join a cartooning for communicators workshop in Brighton. Martin and Martha his partner led four of us through a journey of discovery through drawing and use of language to communicate in simple direct terms. I hadn't drawn for many years; art was something I have always loved yet lacked the confidence to pursue. The workshop enabled me to connect with the idea of simplicity in drawing; finding the key message and developing from there. I found it quite an emotional day, as echoes of past 'you're useless' school days passed by.

On reflection I now know I can use a simple drawing to convey a message; my style is under development and I try to practice in spare moments. Another side to creativity, yet I am sure it has value in terms of increasing my range of communication styles, as well as my confidence in my messages. It has also reshaped my thinking, making me consider the core messages I want to convey.
All this has come about through social media 'SoMe'; using Twitter I have found a new arena for creativity. The aforementioned chats, blogs and vlogs, all make increased links with greater immediacy. This was brought home to me when a nurse contact made via Twitter looked like they could do with some support. I was happy to offer advice and to listen; and now nearly a year has gone by, the echoes of that time are coming around again. On reflection I have to acknowledge that I know there were some days I thought I could have done differently and been a better support. Even so it appears what I did sufficed for that person, at that time.

Reflections and echoes swirl around; often catching us unawares. For me this 'slow-blog' or 'Slog', has enabled to me look at how I have learnt to innovate with modest personal reputational risk taking, using the opportunities social media have offered to be creative.In my work the benefits are that I can see how important it is to allow all the team to reflect and sense the echoes of learning and opportunities that will allow us to grow and develop; from there we can take innovation forward, personally and professionally.

The funeral of a friend who was a nurse

Working in palliative care, the end of life is a daily event, but today it touched me personally. I, and many others, attended a gathering and well attended reunion at the local Crematorium. We were there to remember our friend, boss, peer and co-worker. Of course there many family there too. Her husband had also worked with us. Jenni took the development of Willen Hospice, and its clinical services to a point where a 20 bed inpatient unit was complimented by all the community services with back up from incredible fund raising and retail support.
I know too that Jenni would play down her part, understandably pointing to the team effort involved.

Jenni had trained as a nurse, and went on later to manage a variety of services after leaving the hospice. Whilst care of the patients was at the forefront of her mind Jenni also had the care and development of her staff alongside this too. I think this is why so many turned up today, from all sections of the hospice, current staff and those who have moved on or been wise enough to retire. Many of the people there today came from Willen. I was lucky enough to have two bites of the cherry working there, both times Jenni took me on under her wing. In many ways these two appointments were critical to me in the development of my career, particularly in palliative and end of life care, and in taking me forward as a service manager. 

Whatever the role, Jenni had touched all these lives as well as all the lives of all those whom the Hospice has cared for. As such then the turnout today was a reflection of the esteem and affection we had for her. That a malignant disease should be the cause of her death at so young an age is another part of the story. 

Alongside that is her reputation for enjoying a night out. In the company of friends and co-workers the loudest laugh was hers. A love of gin, as well as other drinks if required, fueled many an evening. Of course Jenni loved her job and her family; she will be much missed.
Jenni leaves a significant legacy; people who continue to clean, cook and care for those who are frail and nearing the ends of their lives; those who have been encouraged to take chances, develop as people and as servants of those who need the care.
At a time when healthcare and nursing particularly are being frowned upon, and the NHS seems to be falling apart, I am proud to say Jenni was someone who taught us all how to do it right; how to enjoy work; and how to make a difference.  I am very happy to have known Jenni, though very sad now that she has left our presence. She was a light in our lives, and I look forward to carrying her legacy into the future.

A terrible thing to have to write...

In the last 24 hours a couple of  social media interactions have linked together to cause me to write. One is ongoing and concerns the care of a dying person; having worked in Hospice and palliative care  for a couple of decades I can claim to know something about this. Added to this is my experience of end of life care that started on my first ward as a student nurse, that was even longer ago.    Follow @nursemaiden on Twitter to see the story unfold, in real time.
The other link was made this morning as I read @RoyLilley and his blog piece of today, see It's all going horribly wrong

As a service provider I am dealing with several commissioners, except there don't seem to be any out there. There are well intentioned folk in positions that have no decision making power; there is no-one in place in their organisation who can negotiate or decide what to do about the current financial year let alone the next one. In the meantime services go on being poor inequitable and not joined up. Commissioning is getting a bad name through this; as Roy Lilley points out the layers of interference and in my view obfuscation are causing serious problems;  in particular I find in creating change on the ground. 

We are not seeing a new dawn of person focused services - despite the efforts of providers to work that way; we are seeing a shuffle of the layers of control - a shuffle in inexpert hands that will be a whole lot messier than 52 card pick up. It is leading to a dying of the light in which the rules and regulations over reporting and numbers will lead decisions on the provision of care. I'm not convinced that concerns about the money (spending or saving) are behind the decisions; only being in a place where having control counts.

All around us though the dying, frail and vulnerable of all ages are only being supported by dedicated on the ground staffs day by day. Often they are kept from doing the right thing by the 'rulers' or vacuum and this is leading to provision of poor, less than best services and no sign that things will improve soon. That is a terrible thing thing to have to write in 2012.

Time to Care, Dignity and Nutrition - a mixed result for nursing and management

This morning in the UK we awoke to the news announcing the publication of the CQC report Dignity and Nutrition inspection programme, see it at http://www.cqc.org.uk/_db/_documents/20111007_Dignity_and_nutrition_inspection_report_FINAL.pdf


The media focused on the poor practice and dubious standards the inspection team found, see  http://www.bbc.co.uk/news/health-15279796. The inspection teams were formed including CQC Inspectors, practising nurses and 'experts by experience' such as members of Age UK. I like that approach, the latter parts of the report explain how beneficial it was to the process and getting a relatively open response in areas under inspection. My own experience in the first Cancer services review conducted by the the original generation of the CQC line, the Commission for Healthcare Improvement (CHI) used nurses and Audit Commission staff. We didn't use patients to conduct interviews though there was work done with seeking their views. We are at last engaging those who are cared for in the process of inspection and evaluation of services. 
There were good practices in place though the consistency varied; it must be acknowledged too that some poorly resourced areas managed to meet the standards whilst others with more resources did not meet them. The report draws attention to the suggestion that mangers are not consistently addressing issues of poor performance (p13).


Alongside this are variations in the application of practice where some managers did not seem to have an accurate knowledge of what was happening, “When we asked about the red tray system there was a mixed response. Some senior nursing staff told us that the red tray system was in use but the junior nursing staff on the ward did not know what the red tray system was. They told us that they had never used it.” (p15).


Another quote was  “All the ward staff we spoke to on the stroke unit said they felt the unit was understaffed and the current levels were not appropriate to meet the needs of the patients.” (p13). 
What concerns me about these three examples is the theme of management competence. Inconsistency of performance should not be a problem if the managers understand how to address the issues and are supported in doing so. It is time to reclaim best practice - and encourage fellow nurses to speak up when poor performance is seen so it can be dealt with promptly.
Management by walkabout has been talked about in the past; it is one way to observe what goes on in your area of responsibility. It makes one visible to the staff, so they can speak to you as well as the people in your care. That would help improve reduce the dissonance between the presumption that those one manages are doing the right thing, and positively making sure they are doing the right thing. You stop looking quite so foolish as a manager that way. And the final quote about "all the staff we spoke to... " - there were presumably more than two (though this should apply even if only one) left me wondering about the support managers gave to staff to raise concerns and take them seriously. And why were the staff letting this go on without taking it further?
Somewhere managers have to be able to strike the balance that encompasses in the phrase 'the people in our care' not only the people who we are striving to help as nurses, but those in our employ for whom we also have a duty of care. Then we might have a better chance to get things right.

Transformation for the future through trust

Another day has gone by at the Help the Hospices conference giving me more to think about. Faith Mwangi-Powell gave us a personal insight into strategic alliances and all the pitfalls and positives along the way. A key theme was trust in each other at personal and organisational levels. In the end the partners will share the risks and rewards of joint ventures; this links to Tim Harford's words of yesterday about taking risks - the small bet. Tim reminded us it was ok to make mistakes so long as we made good mistakes from which learning can take place. Faith echoed this saying we can make mistakes but we must learn not to repeat mistakes; either way we will benefit as organisations as well individuals.
Cooperation was a theme from Tom Hughes-Hallett (Marie Curie) and Julia Palca (Macmillan) - I was not so convinced that Macmillan get the importance of seeing other's viewpoint; Tom was honest and open inviting us to question and involve others in order that we can go on doing good things for our patients.

Inbetween these sessions was an absorbing workshop on personal mastery in leadership by Sally Watson and Jeff Jackson. It focused on the notion that our past is the most important resource in terms of recognising our leadership style and practice. We were encouraged to look back and share in confidence then consider how important it is to let go, and listen to what we can discover by removing the blocks we may have. (This is my simplified version of their slimmed down version of what they use so may not be completely accurate). Once we have done that we can discover new solutions that we can act on.
I felt it left us in place where we would have to trust ourselves; they argued by trusting ourselves and being ourselves we will be aware of the impact we have on others and lead to transforming the situations we face as leaders. 
Then the senior nurse managers met over lunchtime to look at ways to support and network amongst our peers; it is essential for the future, and there were encouraging signs of willingness to participate.

So a day of transformation - in reality and with potential to transform the future.

Storm in a tea cup? Nurses told to buy their own milk at Barts | News | Nursing Times

Nurses told to buy their own milk at Barts News Nursing Times
It would seem a petty restriction, but timing and communication in management is everything. If the Trust responsible for Barts hospital was serious about saving money they'd have done this a while back - see how many comments on the Nursing Times web page show how this has been implemented elsewhere. To do it now at a time when everything at home is getting more expensive shows a lack of sensitivity and dubious PR practice. Has anyone seriously broken down the costs; looked at the cost benefit ratios?
Staff will feel 'demoralised' - when faced with pressures in the workplace the important things for managers to do is keep up the morale of your team. The apparent 'little thing' that contributes to the whole cost saving is just one perspective; to the tired thirsty worker who needs a quick break, or at least a chance to take care of themselves even if only slowing down a minute, it can be the difference between a day of hard work that went well for those in their care, and a day where it all went 'pear shaped' - and harm was done. One day some harm may be done - next day - it gets worse and so on.
On a day when I have a significant loved one having surgery I want fresh keen and well motivated staff looking after them.
Let's get messages straight and clear but have some flexibility too; set up schemes that are fair if everyone has to contribute; make an effort to look at the impact and explain alternatives. Blanket bans are always perceived as negative - and humans tend not to like the negative and will look for ways round such bans.
So managers have to be creative - of course that requires a well motivated and creative management team who are happy and secure in their workplace... in the NHS in England that is so often not what we have just now.
Meanwhile I suggest the nurses at Barts take a deep breath - see the change as an opportunity to negotiate but also to consider what any campaign to reverse the ban will look to those around them. It may be a fight not worth taking on; energies may be needed for bigger battles when jobs - despite lower milk bills are being cut.