Analysis

Dear diary, it’s been another demanding day

Three nurses’ accounts of a shift offer a moving insight into daily pressures in the NHS

Three nurses’ accounts of a shift offer a moving insight into daily pressures in the NHS

Bethany Burgin with colleague Kate Coyle. Picture: John Houlihan

NHS pressures used to be called 'winter pressures', but it is now widely accepted they carry on all year round.

And where once the pinch points were at their tightest in emergency care, spiralling demand and a capacity gap are now system-wide, according to NHS Providers organisation.

Efforts have been made to ensure pressures do not turn into crises. Examples include a £240 million investment in social care in England, announced in October 2018, to reduce delayed discharge.

But here, three nurses in different settings share diary accounts from January and February that show they are working in a service where the pressures are unremitting.

The emergency department charge nurse 

Emergency department charge nurse
Matthew Osborne.

Matthew Osborne is a charge nurse in the emergency department at Southend University Hospital NHS Foundation Trust and a lecturer in the School of Health and Social Care, University of Essex

8am I’m allocated to resus with a band 5 registered nurse. The five-bed resus area already has four patients. Two have been there more than four hours, while the other two have recently arrived and are being assessed for red-flag sepsis.

8.15am Two new patients on their way: a 78-year-old man and a 66-year-old woman with breathing difficulties. Both long-stay patients are stepped down while the other two are still being treated for red-flag sepsis.

9am Both new patients have suspected infective exacerbations of COPD (chronic obstructive pulmonary disease). Arterial gases indicate they might benefit from non-invasive ventilation (NIV) but we only have one machine. I try – and succeed in – sourcing a second.

‘There are more than 50 patients currently in the department. Ambulances are now starting to queue, unable to offload’

9.45am The phone has gone again for a suspected stroke. The stroke team will meet, assess and treat the patient.

10.35am Another three standbys: an 89-year-old found at the bottom of stairs, bleeding heavily from a head wound; a suspected respiratory sepsis in a 78-year-old man; and a third-degree heart block in a man of 52. 

11.15am The first of my patients on NIV has been reviewed by the medical team, allowing the start of the process of looking for a bed. The hospital has been on black alert for a couple of days due to an influx of unwell patients and the site team is looking at placing medical patients in surgical wards to free up capacity in the ED. There are more than 50 patients currently in the department. Ambulances are now starting to queue, unable to offload.

11.40am The trauma patient has a subdural haematoma. Discussion on a transfer for specialist input. Meanwhile, she is admitted to intensive care.

1.30pm Space freed in medical beds for one of my patients on NIV. The other has seen a dramatic improvement so can go to a standard respiratory bed. My colleague and I have got resus sufficiently managed for her to go for lunch. Another suspected sepsis patient is on the way.

‘I’ve been stuck in CT and X-ray with my trauma patient and not had a chance to do much documentation’

2.45pm A band 5 arrives to cover my break.

3.58pm The patient with heart block is now on the cardiac care unit, leaving only two patients with red-flag sepsis in resus. We get a small window to clean and tidy.

4pm Another sepsis incoming.

4.18pm And another red-flag sepsis standby – back to four patients again.

6pm A nurse on the twilight shift has come on and been sent to resus to cover second breaks.

6.32pm I’m now involved in a trauma call: a motorcyclist who came off at 70mph.    

9pm I’ve been stuck in CT and X-ray with my trauma patient and not had a chance to do much documentation. Finally leave at 9.30pm, just 30 minutes after my shift officially ended. I can’t be bothered to cook now, so a burger on the way home it is.

 

The community nurse

Bethany Burgin is a newly qualified community nurse who began her role with Sheffield Teaching Hospitals NHS Foundation Trust in September 2018

Bethany Burgin with nursing student Lucy Kennen. Picture: John Houlihan

8am I have four early insulin administration visits. The first two are straightforward.

8:45am The third patient is hypoglycaemic. I look in the kitchen for food and drink but the patient has little in to quickly raise blood sugar. I treat the hypoglycaemia but the blood sugar continues to drop, so I make the patient breakfast. I send a message to the team leader to say I’ve been delayed. A 20-minute visit ends up taking 90 minutes. I leave, briefly feeling overwhelmed. I’m relieved when the team leader says she has reallocated my last insulin visit to someone else.

10:30am My next patient requires bilateral leg bandaging but she’s upset and refusing the bandages. I use my laptop to show her images of her legs from previous visits and explain how much they’ve improved. The patient allows me to re-bandage her legs.


Watch: Bethany Burgin reveals the daily challenges she faces as a community nurse


11:30am The next patient requires daily bowel care – a joint visit with another nurse. Co-morbidities, medical history and complex family issues mean it’s a difficult visit. On arrival we face a family member’s frustration. My first thoughts are 'how am I going to handle the situation?'. I’m not sure I’m experienced enough. I let the family member talk and realise it’s just that she’s under stress. I finish the visit while reassuring the patient and her relative, and make a note to speak with the team leader to see what carer support we could refer her to.

‘My second unplanned visit of the day is a new patient requiring palliative care. I quickly realise they are deteriorating faster than expected’

12:15pm A call giving me two unplanned visits including a patient in pain with a blocked catheter. I must re-prioritise my workload. This intervention takes 40 minutes.

1pm Return to base for lunch, meet up with colleagues, talk to my team leader and plan the rest of my day.

‘I love my job – you realise the difference you make’. Picture: John Houlihan

2.30pm Following handover, my second unplanned visit is a new patient home from hospital requiring palliative care. Unsure what I’m walking into, I quickly realise the patient is deteriorating faster than expected. The family are extremely upset, the patient is in pain, agitated and requiring pre-emptive medication. I spend the next hour trying to develop a relationship while making the patient comfortable and reassuring the family. I refer the patient on for a night-sitting service and therapy services.

4.05pm I start my return insulin visits and still have two patients who need leg dressings, plus a suture removal to perform before 6pm. 

4.30pm Another nurse is going to help with the rest of my visits. I manage to finish my shift on time.

6pm Reflection on the day: I love my role. No two days are the same and you really know what a difference you can make.

The oncology nurse

Sandra Jackson, senior Macmillan nurse for oncology, London North West University Healthcare NHS Trust

8am Check voicemail messages and which patients are on the wards. Create a shortlist from applications for a vacant post.

Senior Macmillan nurse Sandra Jackson.

8.30am One of my patients in the ward, Tom*, is experiencing difficult symptoms related to cancer: pain, abdominal distension and ascites. He is not well enough to receive any treatment that could help control his cancer. His prognosis is weeks. It is a hugely distressing time for his family. Our role is to provide support and listen. I speak to a palliative care colleague who will meet Tom and his family on the ward later.

9am See a consultant about getting a hormone prescription for a male patient with breast cancer. His GP refuses to give him the prescription. I arrange for it to be available when he comes to the hospital.

‘I notice one of the junior doctors was affected by a conversation with a patient. I tell her she has done a good job and even when we try our best, sometimes we are limited in controlling a cancer’

9.30am Handover with my colleague. Half-way through she is called away as a patient in endoscopy has been found to have cancer. She needs to support the patient while the consultant explains the findings.

9.45am On the ward I review a woman called Bimpe* who has metastatic pancreatic cancer. We discuss plans for going home, and next steps in her care.

10.30am We meet Tom and his family at the bedside. The consultant answers his questions, but it’s difficult for Tom and his family. We tell him about the support available and try to offer him time and space to make sense of this information. It’s a difficult conversation to have with only a curtain separating Tom from the rest of the world. Together, a decision is made to transfer him to the hospice.

11.40am I notice one of the junior doctors was affected by the conversation with Tom. I tell her she has done a good job and even when we try our best, sometimes we are limited in controlling a cancer.

‘Finish, but planning tomorrow. I haven’t achieved everything I wanted to today’

Noon Fill out a form that enables people who have less than six months to live to get benefits at a higher rate and quicker.

12.10pm Multidisciplinary team meeting to review patients with upper gastrointestinal or liver cancers. 

2.30pm Answer emails.

3pm Review existing patient information for those referred on a two-week wait for suspected cancer. The information helps people understand the process and encourages them to attend appointments.

3.40pm Telephone a patient’s relative to discuss care. Update patient records.

4pm Finish, but planning jobs I must do tomorrow. I haven’t achieved everything I wanted to but have prioritised where I needed to be to meet the needs of patients.

* Individuals' names have been changed

 


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