Reflections on a clinical shift: "After 20 years of nursing, this is one of the worst shifts I have ever completed"

Summary

I am one of many staff that undertake additional shifts as bank staff or agency staff. The reasons are varied and personal. This is a reflection on a shift that I undertook a few weeks ago. I have taken the decision to remain anonymous in this account.

Content

I had booked a clinical shift on a ward that was titled an 'escalation ward'. I had no expectations of what this would be, only that I would be part of a team looking after patients. I was surprised at what then happened during that shift.

I reported to the ward as expected. There was healthcare assistant (HCA) present from the night shift, who told me that there was nowhere to put my bag or coat but that it would be ok by the nurses station. Well, it was called a nursing station but that is a grandiose statement for a desk that would not be out of place in student digs. There was no computer on the desk but two 'Computer on Wheels' (another tragic abbreviation 'COWS' in the NHS). Even the chairs would have been better placed in the local playschool, rather than a workstation.

The registered nurse (RN) from the nightshift came back from copying or printing something—again, no printer in this clinical area. (I wonder how many people feel that a desktop computer and printer are essential tools for the clinical area?) It was then I was informed that the staffing for this area was one RN and one HCA. I was on my own as a RN with the HCA. Both of us were temporary staff. Only one of us had a substantive post in the Trust... and it was not me.

As I looked around and waited for handover, I noted that the oxygen ports, call bells and suction equipment were all on a 'ring main,' which instead of being within easy reach in an emergency were about six feet up the wall, out of reach of most nursing staff. How to increase the stress of staff in an emergency, place emergency equipment out of reach unless you stand on a chair, and not every bed had a chair next to it! Indeed, in one of the bays there was little room to place a chair between the beds.

As the handover began, I started to get a little concerned. The suction equipment was out of reach, but as each patient was handed over the thickness of the fluid was added in and there were two or three patients that required thickened fluids—is this a choking risk and how am I going to respond when the suction is out of reach?

Handover is an important part of the nursing process, but we have shortened it to the barest minimum with an assumption that staff know the patients. That does not work in the current workforce climate where there is a reliance on temporary staff to fill the required numbers.

For this shift I was significantly deficient of information. The information I did have was name, age, resuscitation status, presenting complaint, eating and drinking, mobility and likely discharge. There was some other information, but I did focus on how many times “needs a red tray”, “needs assistance of two” was mentioned. There was a patient awaiting cardiology input – should they be on an escalation ward with no fixed monitor—only one mobile monitor for all the observations? There was another recovering from a stroke, same question posed.

Would I be able to reach and use the suction at about six feet above the floor if anyone choked? Had the tube been cut to the right length to enable it to reach the patient? A care space designed from the world of 'work as imagined'.

What struck me throughout handover was that there did not seem to be any consideration of the workload that was being generated from these patients. How can two people ensure that four or five patients get hot food during a mealtime when there is also a medication round being undertaken? Many will say delay the drug round, but this includes time critical medication, such as Parkinson’s medication. Omitting that renders any physio input as null and void as the patient will not be able to move easily. My heart was sinking as we got further into the handover, and I can honestly say that this was very fast becoming a very lonely place to be as the night shift RN left to sleep. I honestly wished I could follow them.

My first job was to bleep the bleep holder to let them know my worries about the shortages in my knowledge. This took about 10 minutes to get an answer. I explained that I did not have a substantive post and with my clinical background there would be a number of tasks that I would not be able to do. I was told that I could rely on the ward clerk from the ward next door while the bleep holder would be able to support me from a ward on a different floor. This made me feel a little better, as I now had some support.

I went to log into the system and forgot that I had changed the password, so managed to lock myself out of the account. Could the day get any worse? I phoned the IT help line and was greeted with a pre-recorded message: “thank you for calling the helpline but our opening hours are 0800-1700, if your call is urgent, please call the operator”. I called the operator who said they would not call the IT help person, as they would be on their way in and it was only 10 minutes until the helpline became active.

At 8 o’clock I called the helpline and was told I was seventh in the queue, wow, but my call is important to them. After 20 minutes I got through to someone who very helpfully reset my password for me.

During this time, the breakfast arrived and the HCA started to give it out, helping those patients that required assistance. I started on the medication round, with a drug trolley that will be familiar to many. Lots of boxes crammed into drawers, difficult to navigate and, for some reason, did not contain all the medications that this ward required. Situation normal; off I went to the ward next door to start begging, borrowing and stealing what I needed.

How long can one drug round for eight patients take? This one took nearly two hours, trying to find medication, administer it, ensuring those with swallowing concerns were supported.

There was one patient that needed transport to be booked but there was also an annotation that they required an assessment of their home prior to the transport being able to take them. I went and spoke to the ward clerk. This resulted in me being told that today was not their day to help this escalation area but was directed to the correct ward for the support. Finally, we managed to decide on the level of assessment and arranged the transportation. Later in the morning I received a phone call from their next of kin, asking what time the patient was being picked up. I explained about the need for transport and assessment. I was then informed that the patient could get out of bed, sit in a chair and there would be people at home to help. None of this had been communicated in the handover. I was really regretting booking this shift. I could do no right for doing wrong. I really felt that I was letting the HCA down, as we were working independently but it was the only way to achieve everything that was expected of us.

I was relieved to go for a break but then realised that I had forgotten the medication for a patient, it was Parkinson’s medication, so when I returned to the ward the first thing that I did was to give this. I was then approached by a speech and language therapist saying that the one of the patients was on a specific consistency of diet—they are all numbered and mean nothing to me, apparently it had been ordered incorrectly. While the therapist was not blaming me, or judgemental, I felt it was just another thing that I should have known and should have done.

I finished the shift and handed over to the late staff. To be fair I could not wait to leave. After 20 years of nursing, this is one of the worst shifts I have ever completed. I felt isolated, inadequate and I let the patients down. The bit I feel worse about is that I feel I did not support the HCA.

I was placed in a position where the environment, the task, the tools and the staffing all mean failure is more likely and success is probably due to the people involved. I have raised my concerns, but I fear nothing will change, nothing ever seems to change.

I wonder when I can just give the NMC my pin back, I am not sure that I want it anymore. I cannot keep letting patients down or failing my team.

This account highlights the importance of healthcare spaces and processes being designed to allow staff to do their jobs safely and efficiently—the author describes their concern about reaching call bells and suction equipment which had been installed too high on the wall. It shows that when designing environments and procedures, we need to consider how staff carry out tasks in real life, rather than in an ideal, hypothetical scenario. This is sometimes referred to as focusing on 'work as done' rather than 'work as imagined'.

If you work in healthcare and want to share an experience of where the design of a process, physical environment or system has helped or hindered you in your role, we'd love to share your story. Get in touch with the hub team at content@pslhub.org

Read more stories from staff on the frontline in our Florence in the Machine series.

About the Author

The author wishes to remain anonymous.