Sunday, October 2, 2011

The Neutral Zone

The thought occurred to me this week - when did we become an either/or society? We seem to be becoming increasingly polar in our opinions, either Microsoft or Apple, iphone or Blackberry, books or a Kindle. Those are surely unsustainable positions. Why can't we acknowledge that there are elements of both which would work for us at different times. After all, when you buy a Kindle it's not like Amazon send a big skip round to your house and take away your existing book collection is it? 

What sparked this off in me was attending a meeting of Healthcare Professionals for Assisted Dying (HPAD) at the Dignity in Dying offices in London.  It was a good meeting, focusing upon how HPAD could inform the healthcare profession's debate around assisted dying and also support doctors and nurses in practical ways...and it changed my mind for me. Not in terms of being a whole hearted supporter of choice at the end of life but in terms of what we should be expecting from the Royal Colleges in terms of their guidance to practitioners. I admit that when the Royal College of Nursing adopted it's neutral stance towards assisted dying in July 2009, I was a little disappointed that they hadn't gone the whole way and come out in clear support. However Professor Ray Tallis made the point that neutrality is the obvious and most desirable outcome. Why? Because it's the only outcome that complete acknowledges the autonomy of the individual. This is not an issue to be controlled by healthcare professionals who set themselves up as gatekeepers, it's an issue that that cements the partnership between the patients and their health carers/providers. We need neutrality in order to encourage our professional organisations to provide support for healthcare professionals who both do and do not support this contentious question and we need neutrality to enable us to direct patients to the best sources of advice, whatever those sources may be. This is not about either good palliative care OR assisted dying, it is, what it has always been, about informed choice.

Finally, I was a little depressed to note that only 66 of HPADs 380 members are nurses. This despite the fact that nurses would argue that they spend more time with patients than doctors, they act as patient advocates and that some polls suggest that nurses are more open to a change in the law around assisted dying. Nurses care about this question so I would hope that more of them will join HPAD and make sure their voices are heard.

Friday, August 12, 2011

Virtual loss, real grief

Like a number of people I have a lot of on-line friends, more if I'm honest than I have in the off-line world. And this week I lost one. One of my tweeps (that's what I call my  friends on the micro-blogging site Twitter)  has died after a long health struggle that he bravely kept to himself. This was a person I had never met in the off line world, didn't know what he looked like or what his off line name was. I know he was tolerant and kind and quirky, I know we shared a love of opera, shoes (he was a self-declared transvestite), take away food and  most importantly a sense of humour. @daminicustard was always ready with a virtual hug when I posted a sad thought or a witty quip, we recommended each other to our own followers and I like to think we made each other laugh. It's hard to think that I'll never get another *mwah*  for giving him a #ff recommendation or making him smile.

So don't tell me that relationships in the virtual world are some how less authentic or meaningful than those in the off line world. If they were the grief I'm feeling at the moment would be much less painful and much less real. As health care professionals this may be an area of loss we have not even begun to think about addressing but it is an area of care we cannot ignore for much longer. Social media has made communication both more immediate and more intimate and working out how to support individuals who have lost people they never really had in the 'real' world is possibly one of the next big challenges in nursing care.

So, goodbye @daminicustard, I'm sad you never knew how special you were, it was a privilege to be one of your Twitter friends and I hope, wherever you are now, you are finally happy.

Monday, July 11, 2011

When did playing outside become a disease?

I couldn't believe when, watching TV the other night I saw an advert for Oralyte for healthy kids. For those who have not come across this before, it marketed in the UK as Dioralyte and is a drinkable  salts and glucose mixture used to help rehydrate patients who have severe intestinal problems and had nifty little animations demonstrating how salts ad electrolytes are lost through sweat and how easily they are replaced by Oralyte. This advert was encouraging mothers to feed this stuff to their children who "become dehydrated when playing outside. I'm sorry....what??????????
In a society which seem sdetermined to prevent children from playing In streets parks and gardens, walking to school and generally rushing around on bikes this seems the final step to far. Kids who are playing outside require (I'm told from my friends with kids) frequent feeding and watering and if this is done the there is no need to seeking medical treatment.
It  seems to me that this is a cynical attempt to frighten parents into buying a treatment for their kids that is unnecessary and redundant. Whilst electrolyte replacement compounds have been used to treat severe diarrhoea in children there is no evidence that in ordinary thirst it is any more effective than ordinary water or fruit juices especialy in healhty individuals.
This does 2 things, firstly it exploits parents by implying that the old way to look after their children in the summer is to make them drink electrolyte supplements and secondly it emphasise a more important trend in today's society to find medical ways of treating ordinary life experiences. Is this how we want our children to grow up - frightened to play in case they dehydrate?

Thursday, July 7, 2011

Feet of clay?

The first professional idol I had was a ward sister called Angela Knight. I worked on her ward at the start of my third year of training and she was the first person that I looked at and thought " When I'm a ward sister I want to be like her!" Fortunately my placement was only for 10 weeks so I left the ward with my awe intact. Since that innocent time I have been sadly disappointed in my ( very few) idols since. Finding an individual I held in great regard operated, on closer inspection, in a cloud of glamour with little substance behind the show, meeting a key nurse theorist who changed the way we think about nursing and finding them to be inarticulate and shy was a massive disappointment. It shouldn't detract from the esteem in which I hold their work but somehow....

And maybe that is the way to ensure that your professional idols maintain their mystique, appreciate them from a far and never, never get to know them!

Tuesday, June 14, 2011

Meetings, meetings

In the 21st century isn't it about time we came up with something to replace the endless and pointless meeting to which we all go. Why do I have to travel 50+ into work to sit in an over or under heated room (depending upon whether it is summer or winter) with only half of the people who should be there to attend "a meeting". I have lost count of the number of meeting that I have turned up for that have been cancelled at the last minute because too many people sent apologies. Why do we have to have "team meetings" it's not for team building purposes because, generally, half to two-thirds of the team are missing and it can't be for communication purposes because, well....half to two-thirds of the team are missing. If something is vital for everyone to know - send an e-mail, or a text, or tweet about it. If you want more people to attend - hold your meeting in cyber-space via Skype. If I hold a meeting, it has a clear purpose, stated aims, a proposed outcome,  an agenda - to which we stick- and is targeted at the people who will help to make those aims a reality. Does it make me naive to if I wish that al meetings could be like that?
I now have two goals for meeting attedence;
1. The pupose of the mmeting, and my contrubution must be clear to me from the moment the invite to attend reaches me.
2. The meeting should not be higher that then first floor of any building.

Actually, the last point has little to do with the effectiveness or otherwise of meetings and more to do with my lack of desire to slog up more than one flight of stairs for anybody!.
If anyone wants to discuss this further, contact me with some diary dates and we'll set up a meeting

Tuesday, May 31, 2011

Who cares?

From time to time, I am "invited" to take part in selection interviews for student nurses. At some point in the interview some one on the interview panel will ask THE question - which is, of course, "why do you want to be a nurse?" To which the interviewee inevitably gives THE response "Because I want to care for people". I struggle a bit with this answer I have to be honest - why is nursing still primarily associated with caring rather than say, a satisfying career, the opportunity to do health care research or a fulfilling academic challenge? If people are so keen to care why not become lollipop ladies/men. They also care, they have a cool uniform and they only work about fours hours a day!

These individuals clearly have a view of nursing that is predicated upon the concept of caring, even thought they often have only the vaguest notion of what that may mean. They come into nurses education keen to care, nurse educators invest a great deal of time and energy in encouraging caring but once such students make it into the stress filled world of clinical delivery...guess what is the first thing to be subsumed?

This is why, in the UK at least, we have things such as the North Staffs enquiry, continuous reports about poor care for older people and only last week the report that doctors are now having to prescribe water to patients in hospital in order to prevent them dehydrating. This is shameful. Its not what potential students mean when they say they want to care, it  isn't what universities are teaching  so what is going wrong?

My friend became a grandmother for the first time earlier this year and found her daughter in such an appalling state post delivery that she signed her out to take her home. Not a bad idea, mother and baby were perfectly healthy, if not being washed, fed or being relieved of an  over flowing bed pan that had been used two or three times but not removed. On top of these indignities, the final words of the "caring professional" as this distraught first-time mother was helped from the ward by her family were "If your baby dies tonight - that won't be our problem".

That's a damning anecdote, but what it is worse is that every one who has fallen into the hands of organised health care, even briefly has a story that is similar or worse. My friend is a strong, assertive woman (wouldn't be my friend otherwise) but she didn't feel that it was worth her while to complain. If we as nurses and unaware that our caring attitudes are eroded by practice and our patients are not encouraged to be the custodians of our caring skills - then what hope is there for caring in health care?

Wednesday, May 25, 2011

Where are the maverick ward leaders of yester year?

Reluctent though I am to turn into one of those annoying people-of-a-certain-age who start every rant/blog with " When I was in clinical practice.."  but.....


When I was in clinical practice if I considered my leadership skills at all (and I didn't) I would have assumed that because I was willing to bend the rules for my patients and support my staff if they did the same I was a good leader. I ran a trauma ward in an area with a large elderly population, often we admitted elderly women whose husbands had never had to cook or shop for themselves so we would 'fiddle' the menus so that we could feed them. We would allow people to have their pets bought into to visit them (although not small babies!). We'd let people visit outside of visiting hours, in fact as a ward team we did all sorts of things that I suspect ward leaders theses days are too scared or too down trodden to contemplate and as a consequence we were a team that had a strong sense of both our professional identity and our professional responsibilities.

I wonder why we see very little evidence of leaders like this in modern health care. Ward leaders seem less willing to go the extra mile for their patients, whether this is because they are less caring (I don't think so) is it because they are frightened about maintaining their registration or have other hospital become places in which the individual has not place? I hope when I fall into the hands of organised healthcare, somewhere to care for me

Continue the discussion this Thursday on #healthcarechat at 8pm GMT+1

Tuesday, May 17, 2011

Poor pain management? I blame Margot......

Without doubt the most significant development in pain management in the UK was the publication, in 1990, of the College of Anaesthetists and Royal College of Surgeons working party report on pain after surgery. It was this report that lead to the creation of Acute Pain Services who would take the lead for improving pain management in hospitals.  Since then analgesic drugs have improved, we have better delivery methods and awareness of the importance of good pain management in a patients recovery has been fully emphasised. So, the question remains – why are patients still experiencing poor quality pain management?

Personally I blame Margot McCaffery. She it was who coined the annoying phrase “pain is what the patient says it is and occurs when the patient says it does”. On the face of it, there is little wrong with this, it raises the importance of believing patients when they say that they are in pain and that can only be a good thing, furthermore it’s catchy and easy to remember – and that is the bit I object to. It seems to me that one could walk into any clinical area in any hospital in the UK and say “Complete this sentence. Pain is what the patient says it is and.....” then brace yourself for the noise of all the staff finishing it off in loud and confident unison. The problem is that although every nurse in the UK knows and believes this statement, hardly any of them act as if they believe it. I think the difficulty if that this short statement has a nice bouncy rhythm, like the old drinka-pinta-milk-a-day or clunk-click-every-trip, to it that makes it easy to parrot and trot out at appropriate time. It has the advantage of sounding clinically empathetic without having to invest a great deal of intellectual effort. Nobody stops to consider that often pain is more than the patient says it is and occurs more often than the patient says it does.  It also implicitly excludes those patients who, for whatever reason, will have difficulty communicating their pain to the health care profession. Thus, despite parroting this annoying little phrase at every opportunity, there is little evidence that patients are believed when they report their pain, significant evidence that certain sections of society and not only disbelieved but labelled as drug abusers when they report their pain, and no evidence at all that a patients previous history of analgesic use is taken into account when prescribing and administering pain killing drugs.
It seems to me that despite all those better drugs, better delivery systems, enhanced prescribing practices and more supposedly patient/practitioner partnerships, pain management is still poor in the UK and it’s all down to McCaffery and her annoying little phrase. Time, I think, for educators and nurses to leave it behind and move on towards genuinely believing what patients tell them about pain and using their not inconsiderable resources to alleviate it.

Curated Chats

Our curated chats can be viewed by following these links:

5th May - Assisted dying

12th May - The role of government in healthcare 

19th May - Pain Management

26th May - Leadership in Healthcare

2nd June - Caring

9th June - Patient choice - open mic 

16th June - Meetings 

23rd June - Genetic testing 

30th June - Online learning

7th July - Professional Idols - are they up to scratch?

14th July - The medicalisation of normal

21st July - Involving patients in their care

28th July - Paying for healthcare

8th September - How do we measure quality in healthcare?

15th September - Should we refuse care based on a patients lifestyle? 

Monday, May 9, 2011

Time to choose?

Ali Handscomb argues that ".. the role of government in healthcare is to balance what is affordable with best quality and outcomes for the people it serves" and that seems to be a point of view that it is difficult to argue against. However, the divided nature of politics in the UK - especially in the present coalition situation would suggest that large proportion of the people will not be so served. Whilst the government feels the need to tinker with health care provision and attempts to sell such tinkering as providing extra choice  to service users, they seem to be missing two key points and they are these...when has increased choice ever been an issue and how does increased choice NOT translate into greater cost ( not less as proposed) Most people of my acquaintance want access to good health care, when they need it and they want it locally.
Many are not equipped to exercise any so-called choice since they don't consider different types of healthcare until they are in a position to need them. My fear is that by offering "choice" the danger of removing large elements of society from healthcare provision is extreme. I live in a fairly diverse neighbourhood where the middle-aged, (say those over 50) tend to be well educated professionals with small families and the younger element... not so much. It is clear that should the government sponsored choice materialise it will be driven by the vocal middle-aged. Good news for people like me who will need hip replacements one day, not so great for those who need teenage pregnancy midwives or  drug addiction services. Cheaper though!
The choice that is being held up as the key outcome of the new NHS reforms seems to me disingenuous. Reform should not necessarily be the role of government, monitoring and auditing of service driven reform that is informed by all of the members of local communities should be

Friday, April 29, 2011

#healthcarechat

Welcome to #healthcarechat.

We will be meeting each Thursday between 8-9 pm GMT (currently +1 as its BST) on twitter via a chat facility called Stanzr. You can register or log in with your facebook or twitter account at http://stanzr.com/healthcarechat

We hope that the topics are informative and interesting for anyone working in the healthcare field. This is an open community and we welcome people from different countries, healthcare spheres and healthcare users. We want to be as inclusive as we can so anyone with an interest can be involved. Each month we will have an open mic session where any questions can be posed to the community and we will be asking for topics from you as a community as well as thinking of them ourselves. We also hope to invite authors and interesting speakers along to become the focus of chats every now and then.

Each week there will be a couple of blog postings here and on Ali Handscomb's Blog  to discuss our chosen topic and pose four questions. Hopefully it will get you ready for the chat and prepare you to think about the topics and questions we will be posing throughout the hour.

We will ask you to introduce yourselves at first so we get to know each other as a community. Carol or Ali will try to always welcome you by name but if the conversation is fast paced and we miss we dont mean to be rude at all nudge us!

As we move through the blog we will ask each question as Q1 - 4 and we would encourage you to put A1 - 4 before each answer and to always use the hashtag when answering. Using a question format makes keeping up with the twitter stream far more simple for everyone following.

At the end of each week we will ask people to post a Take Away which is basically the top thing they have learned form the chat in 140 characters.

It is easier to follow chats on something like tweet deck because then you can open up a column just for the chat and are not distracted by other tweets during the hour. For some really fast paced chats people often also open up twitter and look at the moderators stream as well but it is not always necessary.

As the chat develops we will be posting new information on this blog to make sure you keep up to date with any developments. Most of all we really hope this becomes a supportive and informative chat which helps people discuss current issues and topics in what is an increasingly complex field.

Our chat starts on the 5th May at 8pm GMT +1and Carol has already posted on the topic of Assisted Dying. My blog today has highlighted the questions that will lead us through the topic.

Thursday, April 28, 2011

Why I support assisted dying

Unless we are particularly unfortunate, or live under some form of oppressive regime, everything we do in our lives is more or less under our own control. What we eat, what we wear, where we live who we sleep with/marry/secretly lust for - it's all up to us. Until it seems you come to leave this life, when that happens the decisions about how and where you die can be taken out of your hands  by family or healthcare professionals with little or no regard to your own preferences. I like being in control of my own life and the thought that I will not be in control of the end of it fills me with horror, and that is why I am a supporter of assisted dying.  The Dignity in Dying website defines an assisted death as one where a doctor prescribes a life-ending dose of medication to a mentally competent, terminally ill adult at their request, and the patient then chooses to administer the medication themselves. Assisted dying is different to euthanasia and assisted suicide. Euthanasia is a term often used to describe life ending medication being administered by a third party. Assisted suicide refers to providing assistance to die to someone who is not dying. When it comes to it, I would prefer to chose how and when I die. This is not about doubts about standards of palliative care, not about concerns about adequate pain management and not because I have my doubts about the quality of end of life care in the UK - it is all about ending my life the way I've lived it....on my own terms


I appreciate that there are some people who hold equally strong beliefs, religious, moral or otherwise about the sanctity of life and I respect their right to hold those views. What I cannot understand is why such people are not willing to afford a similar level of respect to me