Analysis

Under pressure: A day in the life of a front-line nurse

Three front-line nurses share their shift diaries from a typical day, offering an insight into the realities of working in an NHS under unprecedented pressure. 

Three front-line nurses share their shift diaries from a typical day, offering an insight into the realities of working in an NHS under unprecedented pressure


Nurses in the NHS face increasing pressure in their day-to-day work. Picture: Getty

Diary one: Liz Alderton, district nurse

7.10am: In office to finish paperwork from previous day, relating to application for NHS-funded care and a referral to Marie Curie night-sitting service.

8.15am: Five-minute drive to see Mary, a 58-year-old woman who has insulin-dependent diabetes and significant mental health problems, heart failure, respiratory problems and a gambling addiction. Gave insulin, prompted medication, health promotion advice, helped catch the pet hamster.

8.30am: Two-mile drive to next patient, which took 25 minutes due to rush hour traffic. Manual evacuation of faeces from Kate, 71, who has a spinal injury. While there received call about blocked catheter.

9.15am: Drove 15 minutes to Mark, 40, who has multiple sclerosis. Changed suprapubic catheter, checked pressure areas, identified increased risk of pressure damage. Advised upgrade to a dynamic mattress.

9.55am: Five-minute drive to Annie, 85, who is blind. Gave enoxaparin injection.

10.05am: Phone call from triage nurse in clinic regarding newly received hospital discharge referral for palliative care. Drove straight to patient, ten minutes.

10.15am: Visit Tom, 69, terminally ill with liver cancer and a prognosis of weeks. Full assessment, including discussions about preferred place of death and resuscitation status, equipment assessment, pressure area assessment. Identified grade three pressure ulcer. Wrote authorisations for nurses to administer medication via syringe driver and issued prescriptions for injectable medication. Phoned surgery to request GP visit and completion of do not attempt resuscitation form. Phoned for delivery of profiling bed and dynamic mattress. Helped wife rearrange furniture to make room for the bed.

11.40am: Drove ten minutes to Valerie, 29, who has Still’s disease and extensive bilateral leg wounds. Arranged GP visit for increased breathlessness and possible fluid overload.

12.10pm: Drove 15 minutes to Alex, 49, partially amputated foot. Joint visit with tissue viability nurse and assessment for vacuum-assisted closure therapy.

1pm: Ten-minute drive to clinic base. Ate lunch while completing paperwork for hospice, Marie Curie referral, equipment for Tom and mattress upgrade for Mark. Started incident report regarding Tom's pressure ulcer. Went in to leg ulcer clinic to assess a wound and prescribe antibiotics for cellulitis, spoke to diabetic clinical nurse specialist regarding insulin regime for PEG-fed patient with unstable diabetes.

2.10pm: Allocated extra afternoon visits to staff and checked online health roster to ensure appropriate staffing levels for next day.

2.25pm: A 15-minute drive to refill syringe driver for John, 59. Had discussion about death, identified unmet spiritual needs. Offered the support of local vicar, which was accepted. Phoned vicar.

3.10pm: A five-minute drive to new patient for a post-operative assessment. Sarah, 45, has had a mastectomy and a breast drain. Was anxious and needed reassurance.

3.45pm: Requested to join junior staff with new patient, Rose, 94, who has multiple extensive grade four pressure ulcers. Undertook wound assessments and care, photography, equipment assessment.

4.35pm: Returned to clinic to complete paperwork, respond to phone messages, deal with feedback from staff. Incident report, safeguarding alert and hospice referral for Rose. Write prescriptions for dressings, review work for tomorrow.

5.55pm: Home.

7pm: Spent 40 minutes uploading patient contacts to computer system.

 

Jason Gray O' Connor, paediatric emergency nurse consultant

7.30am: Receive handover from children's emergency department night staff. There are only two patients waiting to be seen and four children in the short stay unit. However, we are expecting a critically unwell child from a local district general hospital that has no paediatric specialists on site.

7.45am: Six-year-old girl arrives with life-threatening asthma requiring intensive treatment to try and stabilise condition. Following a rapid assessment and initiation of intravenous treatment for asthma, child is transferred to the children's high dependency unit.

7.48am: Medical emergency call activated on children's critical care: 15-year-old child experiencing a respiratory arrest. As a senior nurse on site, I attend to assist with stabilisating the child's condition.

8.15am: Attend hospital bed meeting with ward managers and directorate lead nurse to discuss availability of beds for emergency admissions and whether the hospital can continue to accommodate elective admissions with current emergency department workload. Discuss staff-to-patient ratios to ensure safe staffing levels throughout the hospital.

9am: Attend joint medical and nursing handover in children's emergency department. An additional seven children booked in for emergency assessment and treatment.

10am: Assist with difficult cannulation of critically unwell child being treated for sepsis, after request by medical staff.

10am – 2:30pm: Manage the patient flow throughout the children's emergency department, supporting medical staff and nurse practitioner service.

2.30pm: Attend afternoon bed meeting to review bed capacity. Fortunately, there are ten beds available for the rest of the day, with adequate staffing.

3pm: Medical emergency in children's emergency department: 11-year-old child with cerebral palsy requiring non-invasive ventilation. At the same time, staff deal with a growing number of attendances in the waiting room, and the waiting time climbs.

3.15pm: Receive the hospital bleep from the duty manager, who requests that I take the bleep as the most senior nurse on site for the evening. This adds additional managerial responsibility for the children's hospital, including the admission of patients for specialist treatments that are not available in our neighbouring hospitals. 

4pm: Receive phone call from orthopaedic team requesting we accept a child who is being repatriated from Spain following a road traffic accident. To accommodate this admission, I have to consider the workload and potential admissions in the children's emergency department, where there are five children waiting admission, leaving only five beds for the night shift for other admissions. The neighbouring hospital did not want to take the child due to the seriousness of the injuries sustained, so I spoke to the surgical ward to ensure a bed was available, so that we could get the child back to the UK as soon as possible.

4pm: A parent attends with an 11-day-old infant with sepsis. This requires the attention of the senior medical team to initiate treatment.

5pm: The number of attendances increases significantly, with 12 patients booking in over a 30-minute period. This affects triage waiting times and I allocate an additional nurse to help, to ensure all children are triaged within 15 minutes. I also monitor the trauma and illness stream to ensure the timely management of the traumatic injuries by the nurse practitioner team, and prioritise those children with illnesses to be seen by medical staff. This ensures that there are timely decisions made and no patients waiting in the department for more than four hours.

5.30pm: Short stay unit is filling up, with children requiring less than 24-hour admission to hospital. However, this adds to the nursing workload, with the need to allocate one of the emergency department nurses to manage up to six children. Numbers continue to rise in the children's emergency department as expected, and we have ten patients waiting to be seen.

7.30pm: Handover for night shift and outstanding patients in the department.

 

 

Hilda Hayo, chief admiral nurse and chief executive of charity Dementia UK

8-9am: In my CEO role I catch up with emails that come in late on Friday and over the weekend.

9-10am: My shift working alongside five colleagues on the Admiral Nurse Direct helpline begins. A caller tells me about their wife, who was recently diagnosed with dementia. Her memory has deteriorated over the past few months, and she has become repetitive. He is finding it difficult and wants advice on how to respond. Also give advice and support to a specialist nurse requesting more information about Admiral Nurse services in her area.

10-11am: Email from a man with concerns regarding his mother, who has early stage dementia. His stepfather has many physical health issues and spends large parts of the day in bed. This has been impinging on his mother's condition as she is becoming isolated and, as a consequence, often phones her son saying she is lonely and frightened. We speak about befriending schemes in the area and services and support that can help his mother get out of the house during the day.

11-12pm: Phone call from a woman who is worried about her father's failing memory and reduced living skills. They have been to a GP repeatedly, but feel he has not listened to the family's concerns. The daughter wants advice on how to get an assessment for her father and we speak about how to get a referral to the memory assessment service.

12-1pm: Phone call from a man who requests advice and support regarding his father-in-law, who has vascular dementia and multiple health problems. This morning, the father-in-law had a rash, was in pain and has a pressure ulcer on his sacrum. I arrange a GP home visit. Receive phone call from a man whose mother has been diagnosed with Korsakoff's due to a history of alcohol misuse. He is worried about her disorientated state and says she appears to be hallucinating. I arrange a GP home visit.

1-2pm: Phone call from a woman regarding her father recently diagnosed with dementia. Over the past week he has become moody and miserable and has started to have visual hallucinations, believing people are trying to kill him. GP due to visit but the daughter wants to know what to say and asks for advice on how to cope with her father.

2-3pm: Phone call from a man who says his wife was diagnosed with dementia five years ago and is now dependent on him for all her care needs. Over the past week she has not been able to stand or sit up straight. I advised him to contact the GP for a home assessment.

3-4pm: Email from a woman who is worried about the effect her grandmother's change in behaviour is having on her family. Speak about services, support and techniques that could help the family cope.

4-5pm: Phone call from a woman who is worried she has the symptoms of young-onset dementia. Speak about her concerns and establish what she is experiencing and she recognises that the changes in her behaviour are due to another cause. Phone call from a man about his father, who has been diagnosed with dementia, is living alone and is neglecting his activities of daily living. He wants to talk through how he can broach the subject of long-term care with his father.

5pm-6pm: In my CEO role I catch up with emails and phone calls.

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