Caring in hospitals
Caring in hospitals

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Caring in hospitals

2 A day in the life of a hospital ward

In 1996, we visited Ward 29, one of two gastroenterology wards in the medical unit, and recorded the views of patients and staff. The ward has 24 beds. Its patients were women and men, across a wide age range, suffering from digestive disorders – for example, stomach ulcers, Crohn's disease, ulcerative colitis, cancers of the digestive system or problems with liver function brought on by alcohol abuse. Because it was winter the ward had more elderly people than it would have at other times of year, and staff underlined the pressure they were under to find enough beds.

Probably everyone would agree that Jackie, the ward sister, is the linchpin of Ward 29. She qualified as a general nurse six years ago and has been working in this post for about 18 months. Hers will be the first main voice that you hear on the audio clip as she describes her morning shift. Dave, the senior registrar, speaks next. One rung below the consultant, he is the doctor who oversees day-to-day medical work on the ward. Ann, the health care assistant, is voice number three. Although she started hospital work as a domestic, she explained that she ‘always wanted to do more’. Once her children were older, she moved on to the direct care role that she describes. (Later in this part of the audio clip you will hear James, a nurse, and Susan and Jack, a patient and her husband.)

These are all real people, talking about a real day in the life of a real ward. With their permission, we have used their first names (as they indeed use them in speaking to each other). However, we have edited the clip at points where they use the full names of patients to protect patients’ confidentiality.

Audio: click below to listen.

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Skip transcript: Section one - Working on the Ward.

Transcript: Section one - Working on the Ward.

Working on a hospital ward means different things to different people. Here, several staff, a ward sister, a senior registrar, and a care assistant, all describe their daily routine. First the ward sister, Jackie.

JACKIE
We work three shifts. First shift half past seven till half past three that's called the morning shift. The late shift starts at quarter past one and finishes about quarter past nine, then the night shift starts at quarter to nine at night and finishes at quarter to eight, in the morning.
The shift I'm mainly work for continuation things is mainly the morning shift and we come on about seven thirty, and we have to take a hand over from the night staff: so they tell us any changes that have happened to the patients overnight. Then usually start giving out the medications, and then once that's under way, I either manage to get finished with that or the doctors come on and do the ward rounds. So the ward rounds then start, and they can go on for quite some time, and I usually end up doing those ...
WOMAN DR.
That's negative isn't it.
JACKIE
Yeah .... His biggest problem is that he he he hiccups all the time to the point where, he can hardly he can't swallow he can't talk, and it's a constant thing. Apparently when they were scoping him last night it was, a problem, and that seems to make him him vomit.
DOCTOR
Hi.
PATIENT
Hi.
DOCTOR
My name's doctor .... I'm the doctor that works on the ward, alright. How are you doing?
MAN
Well apart from hiccups not too bad.
DOCTOR
Is this a new thing or ... ?.
MAN
It is I've sort of brought them with me and I don't want to take them home but er.
DOCTOR
How long have you had them for now then?
MAN
About, going on for about a fortnight well enough isn't it.
DOCTOR
Erm.
MAN
I think I've got them permanent
DOCTOR
Do you get them at night or.
MAN
Oh yeah, I get them all day.
JACKIE
Constant ... making himself very popular
MAN
Yeah, and I can't control them that's the problem I mean..... (Fade down)
(Fade Up) That's why they never have it at chemist.
DOCTOR
INAUDIBLE
WOMAN
Pardon.
DOCTOR
Nifedopin.
JACKIE
Is that what it is?
DOCTOR
Yeah.
WOMAN
Oh right. Well it's a really common one. INAUDIBLE
DOCTOR
It's just got a posh name.
MAN
Yeah.
WOMAN
and er have you got these down as well because he has.
DOCTOR
Yes we've got those yeah.
WOMAN
You'll have to get repeat prescription for that INAUDIBLE
JACKIE
Well what will happen is our phannacist will .... (Fade Down)
JACKIE
In the meantime there's usually the physiotherapist, dieticians, social workers, occupational therapists, usually coming on to the ward and wanting to sort of have some communication about their patients that they're caring for. So, I jig in and out of the ward round talking to them. Then usually it's a case of helping out, enn doing some sort of caring for the patients if they need assistance with say dressings or something like that that the, maybe the unqualified nurse who's looking after the patients are doing that can't do. Those things if they're doing some kind of observation, such as the the health care assistants don't do blood pressures or, they don't take blood sugar measurements so I'd do those for them as well.
Usually there's a lot of telephone calls to be made and a lot of the conversation on the telephone. That's the normal course of events up to about eleven or twelve o'clock and then you usually do the medicine round again. Then in the afternoon there might be another ward round, if not then usually it's erm people's relatives have come to visit so there's a lot of talking to patients and their relatives in the afternoon. Catching up with other things from the morning such as social problems or, 0 T things. Sometimes go, there's der ... various meetings that I go to such as we have a sisters meeting. Or if I have to go see the nurse manager about the budget or something like that. So sometimes in the afternoon I'm off the ward for an hour or so doing things like that. Then we usually hand over, the patients to the staff that come on in the afternoon, and I usually do that, and about half past three it's time to go home.
End transcript: Section one - Working on the Ward.
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Section one - Working on the Ward.
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Activity 1: The ward sister's day

0 hours 10 minutes

Listen to the audio clip. At this point, just jot down as you are listening the different types of people that Jackie deals with in the course of her day. If you have worked on a hospital ward yourself, or been in a hospital ward as a patient or as a visitor, see if you can add other people who might well be on the ward on any one day.

Discussion

We tend to think of a hospital ward as a place where doctors and nurses work. In fact, as you have just heard, many more people than this both work on the ward and visit it. Jackie referred to the nursing staff from the night shift who hand over to her at 7.30 am. The need to consult the pharmacist was mentioned when she was interacting with a patient and a doctor, and she talked about ‘jigging in and out’ of the more formal doctors’ round to deal with the physiotherapists, dieticians, social workers, occupational therapists. In the afternoons, she said, she spends a lot of time talking to relatives as well as sometimes going off the ward for a while for a sisters’ meeting or a meeting with her manager. There are plenty of other people she might have mentioned. She did not talk about the regular visits of the phlebotomist to take blood or her interactions with the ward clerk or the housekeeping staff. These, and the person bringing newspapers, are a very visible part of the busy ward scene. Nor did Jackie mention any kind of maintenance work. (I came up in the lift with the plumber, who was trying to find which ward had blocked drains.) Jackie did, however, mention the many phone calls that she makes, dealing with social problems, carrying out procedures that care assistants cannot do and, as you will hear later, trying to ensure that things are right for a patient returning home.

Figure 2.7

An example of one ward and one morning like this is not necessarily representative of others. But it is certainly the case that large numbers of people routinely visit acute wards in hospital. In a study of the management arrangements of 14 wards in Wales, a team of observers recorded comings and goings over a period of three days. They calculated that each day an acute ward is visited on about 125 occasions by staff who are not based on the ward (e.g. doctors, physiotherapists, porters, chaplains, phlebotomists and nurses from neighbouring wards). The demands they make upon the time of staff varies from zero for a porter collecting pathology samples to over four nurse-hours for a medical ward round:

The authors further calculated that a member of the ward staff had to stop what he or she was doing on average more than 36 times in each day. And the figure of 125 people did not even include family and friends of patients – a large number if open visiting was the norm. The pattern did vary, however, between different types of wards. A more specialised ward or a longstay ward for older people for example might have many fewer people in evidence.

(Hawley et al., 1995, p. 261)

Certainly, as Jackie's description on the audio clip makes clear, there is a lot of co-ordinating to do if care arrangements are to go smoothly.

Audio: click below to listen.

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Skip transcript: Dave, a senior registrar in medicine.

Transcript: Dave, a senior registrar in medicine.

Now you'll hear from Dave, a senior registrar in medicine.

DAVE
I am in effect the person that is covering all members of the team below the consultants and we have to sort of oversee all of their activities. This is junior medical staff as well as the patients who are not necessarily directly under me.
My day would start at between quarter past and half past eight, where I pop on to Ward 29, as well as any other wards where we have patients just to see if there've been any major problems over night with any of the patients. If they have, then I will try and deal with them at that point to give direction to the, the senior house officers and the housemen during that day so that they will know in which direction to take the investigations and care of these patients. Following that, round about nine o'clock- quarter past nine I will have an allocated slot, now that may be for example, this morning that was a colonoscopy list, so I was down in the endoscopy department, from nine until about quarter to two, doing my list which involves both in-patients not necessarily from our wards, there were some from our wards but, we provide a service for the whole hospital, and indeed the whole Trust.
And following that today, enn no time for dinner that's why I'm so thin, we then went on to, we had a consultant ward round, which is one of two a week where, er my boss goes round his patients on the ward, and he's accompanied by me and the other members of his time, sort of his entourage if you like, and we specifically go over er in some detail, er the care of our - the investigations the presenting complaints, the diagnosis, what are we doing for them. What, problems do we anticipate and when can we look to getting them home, because that is a major priority at this moment in time with the bed shortage.
Ideally, all of our patients would be on one of two gastro-enterology wards, but it doesn't work that way. When you get people coming in off the street, as it were from the general practitioners, from accident and emergency, they go into which ever bed is free at the time and so hence our particular patients can end up anywhere. At the moment it's not bad, we have patients on five wards only, but it does mean an awful lot of traipsing around in between various wards. If they were all on the same ward it would so much logistically easier, and geographically easier to manage them effectively.
Well we've got to past lunchtime well, er yes the lack of lunchtime. We've been on the consultant ward round, which has taken in Ward 29 as well as the other wards where we have patients. On this particular day I then have an allocated er teaching session for the final year medical students. Their er final exams are coming up in six weeks time and they have an, what's called an intensive teaching month, where they get lectured or taught by various specialties, and that's what I was doing from four o'clock to five o'clock.
I have a couple of problems with people who have been booked for procedures tomorrow, who there is no space to put them on so I've got to go and sort that out, and then following that I will do a a final call in person to the wards, as the day started, to see whether there are any problems that we can anticipate might occur during the night, to give the on call staff a bit of direction as to, you know, what they might anticipate and what if anything, to do about it. And then, I try and go home, but generally that's some time between seven and eight.
DAVE
Now then how are you feeling this evening?
WOMAN PATIENT
I'm feeling fine.
DAVE
Good.
PATIENT
and and as I say my husband said when he came this afternoon he said, oh you look a hundred percent better.
DAVE
You certainly are looking a lot better you're you're ti ...
WOMAN
A a a hundred percent better.
DAVE
You're far less jaundiced that's for sure, that's good.
WOMAN
Erm.
DAVE
Now do you remember much about that test that we did yesterday.
WOMAN
Yes.
DAVE
The er, because it wasn't very pleasant for you was it.
WOMAN
No no.
DAVE
When we stretched up your gullet.
WOMAN
No.
DAVE
Tell me, before you came in to hospital did you have any problems swallowing? Could you - I mean if you ate meat and and er and vegetables could you swallow it down alright or did it get stuck anywhere?
WOMAN
Sometimes it got stuck a little bit but not a lot.
DAVE
Right.
WOMAN
not a lot.
DAVE
Have you no, well I'm not surprised because it was a pin hole, er the gullet was narrowed right down to a pin hole, and we really had to stretch it right up. Have you noticed any difference we've stretched it up?
WOMAN
Yes yes.
DAVE
ls it easier to swallow.
WOMAN
Yes it's easier to swallow now.
DAVE
That's good.
WOMAN
Yes.
DAVE
That's good we've found the source of the bleeding by the way .... (FADE DOWN)
(FADE UP)
WOMAN
Yes. It's all oh.
DAVE
Certainly is.
WOMAN
That's marvellous.
DAVE
So we've just got to make sure that we'll get all these drips and things down one by one.
WOMAN
Yes yes.
DAVE
and I think you should be ready to go home start of next week probably.
WOMAN
Next week.
DAVE
Yeah probably .... (FADE DOWN)
(FADE UP)
DAVE
Good evening, how are you doing?
MAN PATIENT
Well, not too bad at all.
DAVE
When was the the test? Was was it early this afternoon?
MAN
Er about half past one I think.
DAVE
Half past one. How did you find it?
MAN
Er, well I never felt a thing.
DAVE
Good, so the sedation worked well.
MAN
Yes.
DAVE
Okay. Let me just have a look at you .... (FADE DOWN)
(FADE UP)
DAVE
You will need to have a chest X-ray later on tonight. to make, because there is always a small risk that we can, tear the oesophagus or the gullet when we·do this.
MAN
Yes.
DAVE
It's a very small risk, but we need to do that X-ray before we allow you to eat.
MAN
Right.
DAVE
Alright.
MAN
Yes. Can I have a drink of tea then as well.
DAVE
After you've had your chest X-ray yes. Mug of tea is is allowed.
MAN LAUGHS
MAN
Okay if if all.
WOMAN
Can we just ask you about, about the bleeding.
DAVE
Which, go on tell me about the bleeding.
MAN
Well, every every night I'm asleep and without any warning whatsoever ...
DAVE
Yeah.
MAN
Er, clotted blood and everything else runs out ofmy mouth ....
DAVE
If you, if you imagine that the the the tumour so the the cancerous growth within the gullet is a load of cells which are ... (FADE DOWN)
(FADE UP)
Help to stop the bleeding.
MAN
Ah.
DAVE
Okay, but it it you may find, that that is a recurring problem in the future. So long as it is not a lot of blood, it's not a problem it's not going to do you any harm .
Obviously it's not nice when you when you cough blood up erm, but it but it's not going to do you any harm.
MAN
Oh.
DAVE
Okay?
MAN
So, it's it's a brighter few weeks.
DAVE
Well we hope so we hope so.
MAN
I hope so too.
DAVE
Indeed. Weather's taken a tum for the better and you're swallowing better.
HELEN MADDEN
And finally here is Anne, a care assistant.
ANNE
Shift starts at half past seven, and the first thing we do we have hand over from the evening staff the night staff to find out what's happened in the ward over night, and that usually takes about twenty minutes. Then we go round and we give the patients breakfast we serve up breakfast on our ward. People thafcan't get out of bed we have to help them get out of bed, sit them in their -chairs get them ready for breakfast, help to feed them if they need feeding, and then like after breakfast, while nursing staff are doing drugs they go round and do the medicines, and we're helping to feed patients that need feeding and get out of bed, and then it's like time to do observations and help with washes and things like that.
Health care assistants are not usually involved in doctors rounds, they're carrying on with the everyday things on the ward while the ward rounds are going on with the qualified staff. So we'd be helping patients that need washing and making beds. Chatting to patients sometimes that need a bit of company and things like that. and a lot of patients just need someone to talk to you know they want you to sit down and talk to them for five minutes or so.
After lunch, we might to observations again. There's another round of observations. People need weighing and, we send of samples whatever samples are needed, and the ward stores arrive. We have stores to put away unpack the stores, put them all away where they belong. No I think the morning shift is much busier than the afternoon.
As a health care assistant we do everything that the staff nurses do, apart from like doing the medicines and, obviously, drugs - anything to do with drugs we don't do anything like that. But, the job's very much like a nurse's job really.
End transcript: Dave, a senior registrar in medicine.
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Activity 2: Contrasting routines of staff on the ward

0 hours 20 minutes

Listen now to the next Audio clip where two more of the staff describe their day – Dave, the senior registrar, and Ann, the health care assistant. As you listen, consider the following questions.

  1. What are the main differences in the daily routines of the three speakers you have now heard?

  2. Who is most available to care for a patient, and what concerns other than patient care does each of these three have?

You may find that you need to listen to all three of them once again in order to prepare your answers.

Discussion

  1. There are different ways of approaching this, but I was struck by how very different Dave's day is from that of the other two. For Jackie and Ann, the ward is their workplace. They are there for the whole of their working time although, as Jackie says, she might leave for an hour for a meeting. A doctor, by contrast, might be in any number of places in the hospital. For a start, Dave's patients are on five wards, not one. Not only does he visit the wards, but the patients from this ward, other wards, and indeed from outside, visit him in the endoscopy department. There are of course differences between Jackie and Ann. Ann spends much of her time doing hands-on care. Jackie, you might remember from earlier, does get to do some hands-on care, and there are some procedures which Ann as a health care assistant cannot do – administering medicines for example.

  2. Of the three, Ann is the one who is most available to care for patients. Did you notice how she emphasised the importance of talking to patients? She does other things too, for example attending to stores. Jackie, you heard earlier, does a great deal to ensure that things run smoothly on the ward. She is co-ordinating, sometimes minute by minute, she is filling the gaps, dealing with crises, offering support and advice to the nurses on her ward, as well as some of the time engaging in direct patient care tasks herself. Dave carries out technical procedures and discusses their care with patients face to face. He sees an important part of his role, however, as supervising more junior medical staff and he also teaches medical students. Although he did not mention it, he is also studying when he can in order to pass the exams which will mean he can apply for a post as consultant (see the box below).

Jackie, Dave and Ann all have responsibilities that go beyond direct patient care.

Who's who among the doctors?

Would-be doctors spend five years as students in medical school. They must then complete one year as House Officer (six months in medicine and six months in surgery) before they are registered. Then come two to three years in Senior House Officer posts and, unless they train as general practitioners at this point, three to four years as Registrar followed by perhaps four to five years as Senior Registrar before they can apply for Consultant posts. Few can hope to move out of the training grades into consultant posts before their late thirties or early forties. Moves are afoot to shorten this time by creating new specialist registrar posts and abolishing the two grades of registrar.

If two consultants have patients on a ward, counting all the junior grades, there are likely to be at least ten doctors who might visit the ward.

Audio: click below to listen.

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Skip transcript: Staff on ward twenty nine

Transcript: Staff on ward twenty nine

Members of many different occupational groups need to work closely together for the health and well being of patients. Primary nursing teams are used on this ward. But just how different are doctoring and nursing? Do members of both groups value each other's work equally? Here again are the staff on ward twenty nine. First James, a primary nurse.

JAMES
The idea is that we divide the ward- the patients if you like - and the nurses into three different teams, which we call primary nursing teams, in those teams we then have, the primary nurse which is myself, associate nurses which generally tend to D grade nurses, and health care assistants, and you're all, in one team together.
The idea is that you would hopefully work as a team in co-ordinating the care for the patients who come in un ... under your care as in the red team. In our teams we have eight patients each. The idea would be that I would normally prescribe the care or plan the care, for those patients. In reality it doesn't always work like that and besides which the associate nurses that are in the teams have those skills anyway from their training.
So often that sort of role is shared out amongst the qualified members of the team. It's generally one way of co-ordinating the care, for the patients on the ward. They would hopefully be in good continuity of care, as they sort of erm, are cared for by one team.
JACKIE
On my ward there's three primary nurses and they're all quite senior nurses, and they're very good at what they do in terms of, they do plan the care and they do look towards planning discharge and things. The thing that I feel is that they're not there twenty four hours a day and, that planning has to go on even when they're not there. I try not to interfere with what they do, but I try to make sure that things run smoothly, and the flow continues even if they're not there. So I try to talk to them about the, what I'm doing and what they're doing
I mean I think, that sometimes my experience allows them to make plans and to make decisions, and to learn I suppose so, that's why I think I give a lot. I like to know what's going on, I like to be a part ofit, and I think that comes from the way that I was trained which is different to now. Whereas we all used to take charge of the ward, and when you were in charge that meant you knew everything about everybody and, a bit of a power thing I think.
ANNE
Before primary nursing, you know start one end of the ward and do all the observations, do all the beds, all the washes things like that, whereas now, you have like eight patients each to look after, and you look after those eight patients. You do everything for those patients. and I think that's really nice, because they get used to one nurse looking after.
Well I've been looking after a lady now for say, only two weeks I've got to know her really well and she was the type of lady that when she went home from hospital, she's going home from hospital today, and that she needed a lot of extra help when she went home, so we have to arrange all that in hospital, so that she can go home and have the extra help. So I went on the home visit with her with the occupational therapist, to see how she managed at home, and the things that she needed and she didn't need and. It worked really well. · Yeah it were really really good because, you went to see whether she could manage in the bath'. out of the bath, could she manage making a cup of tea. How would she manage with her tablets, could she take the tops of the bottles. Who did her shopping, could she manage to push a hoover, all things like that that you need to know about elderly people before they go home.
(Anne talks to Nellie, a Patient)
NELLIE
Yes I've been pleased with my meals. Well I've been pleased with it all way round. All I'm er, waiting for anxiously is home sweet home.
ANNE
Just waiting to go home now you're right yes.
NELLIE
That's right.
ANNE
Yes, is Jill going to be waiting for you when you get home?
NELLIE
Yes Jill's going to be waiting, and I mean, she'd make up for two really because she's, you know so nice. Never grumpy.
ANNE
And this home care lady's coming to see you at home isn't she, to see what you need when you get there.
NELLIE
Yes erm INAUDIBLE yes erm. I'mjust INAUDIBLE that's what's happening today.
ANNE
Is your transport booked for morning or afternoon Nelly?
NELLIE
Well I'm hoping it's afternoon, and I'm living in hopes.
ANNE
You've got everything you need for when you go home you've got your house keys haven't you.
NELLIE
Yes.
ANNE
... You've got your coat and your shoes to go home in?
NELLIE
That's right yes. I think I've got INAUDIBLE
ANNE
And was Jill going to get you some shopping for when you get home?
NELLIE
Yes.
ANNE
She said she'd get you some like bread and milk.
NELLIE
Hopeful, bread and milk you know main, and you know I'm not short of a little bit that you can fall back on -you know - if it's only a tin o baked beans. LAUGH
JACKIE
Home care will go in to see her tomorrow. Okay, she's got her her central heating's on and her milk and her bread and everything, but they were concerned that she couldn't manage her tablets from now until tomorrow, and Jill the neighbour rang to say, make sure she's alright with the dossit box before she comes home. She hasn't got the dossit box filled.
ANNE
.. Because Jill doesn't live nearby .... Jill only visits on Thursday evening.
JACKIE
Yeah.
ANNE
But she was going to be there for when Nelly went home. So what do we need to do now?
JACKIE
What tab ... I need to find out what tablets she's on really.... She's on the M S T so I really don't want her to be going home without her knowing exactly what she's doing.
ANNE
She was on M S T at home before she cmne in because I got all those M S T tablets from her home a bit back. So are you saying that ....
JACKIE
I'll have a word with Tracy.
ANNE
Jill wanted to be at home when Nelly got there so we could show her how to use the dossit box the first day.
JACKIE
We needed to make sure that the home care at least would be making sure that she knows how to use take her tablets. They can give her them you see and prompt her to take them.
ANNE
I wonder if the pharmacy could do the dossit box the same day and Jill could collect it for her.
JACKIE
Today?
ANNE
Yeah.
JACKIE
We'd need to ring her pharmacy ....
ANNE
We've got the number and everything here. (FADE DOWN) I like looking after patients that need a lot of help really. You know like as regards hygiene and, people that can't do a lot for themselves. It's nice to care for them, and know that you've got them washed and dressed in the morning they've been laid in their bed all night You've got them up, they smell nice, you've combed their hair you've put curlers in, things like that. As a nurse you're there any time of the day for anything. You're there to talk to, to cry with to laugh with. If you can't look after yourself you're there to do things for people, and to look after the medical side I suppose.
JAMES
We have a patient on the ward at the moment who's prognosis so to speak isn't very good. Something happened that upset her on the ward, something to do with another patient. Just feeling able to sit with her and to, help her sort of discuss the feelings she was having at that time so that, after half an hour or so she felt more comfortable with what had happened.
JACKIE
I think, giving good care is listening to what the patient and the family want, first and foremost, because I think that's something that doesn't always·happen. Keeping the patient and the family well infonned, is another thing. Making sure that they feel physically as well as they can do in terms ot: being clean and, making sure that they've been fed and making sure that they, they know their way round and things like that. Treating everybody with respect and with kindness, I think that's giving good care.
ANNE
I don't think the doctors see the patients the same as what nurses do. I mean they're more, I'm not saying more interested but they're more there to look after the illness. You know the patient's come in to hospital obviously with an illness. I think the doctors look more to what's wrong with the patient as to the patient as an individual. I don't think the doctors realise that we do during the day. You know they just look after the medical side of things.
JAMES
It's not just a case of when the patient's considered medically fit they can be discharged. We wouldn't necessarily consider medically fit as being the time when they should leave hospital, if there are social problems as well, that need to be taken care of. I feel that the doctors we work with at the moment are very much aware of that. Whilst they may consider some patients as being fit for discharge they always, ask us about the social side of things as well. Medicine to me seems to be changing. I get the feeling that there is, a change more towards a a more caring outlook.
DAVE
Nursing staff are vital. I can't be there all the time, they are my eyes and ears, so . ' they basically watch over the patients for me and will let me lmow of any changes either good or bad, that are - that may be important. I you're perfomring a procedure, maybe putting what we call a central line which is a a drip into the internal jugular vein in the neck, or a liver biopsy or putting a drain into a chest. It's very helpful to have an assistant there, someone who can help you with the the practicalities of it and also talk to the patient. Because whilst you're concentrating with your tongue in between your lips you're not often able to talk er er you know about bits and bobs to to relax them. We are in it for the same goal. In effect we are two parts of the same arm, working in the same direction. Doctors can be accused of just concentrating on the diseased heart rather than the heart within the patient. But if you care then, you care which ever branch of caring you're in.
It's far easier for nursing staff to get heavily involved because they are there all the time. The thing about medicine is, you you get bleeped off, you get bleeped somewhere else, you, you know you have a ward full of patients. But the nursing staff have fewer patients, and as such it's it's more easy to get em ... embroiled into the emotional ranglings that's going on and it, you know it can be, that can be a very rewarding part of it, but it can also be very destructive, and has lead to a lot of people I know leaving nursing. They can't give of their best unless they're involved, but the emotional turmoil and, distress that it causes by being involved time and again, it just wears them down. You can't personali:re it too much otherwise you get too involved but, the the basic question I always ask myself is, if this was my dad, or my brother, what would I want somebody to do for them, what I want them to say to them to explain to them, or to you know, to treat them or sometimes not to treat them. And, that way I t1!ink it's it's, I find it easy to get up in the morning look yourself in the eye in the mirror and say, "I did what I felt was right."
End transcript: Staff on ward twenty nine
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Activity 3: Different approaches to care?

0 hours 30 minutes

Now play the audio clip. First, James, a qualified and experienced nurse, describes the way work is organised into what nurses call ‘primary nursing’ teams to provide greater continuity of care, and Jackie comments on this from her own point of view. You will then hear Jackie and Ann planning the details of a patient's discharge. Ann had been on a home visit with the patient. Concentrate in particular, however, on the later part of this section, where first Ann, then the others, discuss nurses and doctors and their contributions to care.

  1. Do the speakers feel there are real differences in how they relate to patients?

  2. Do they all value each other's work equally?

Discussion

  1. Different people pick out different things as rewarding. James, the primary nurse, singles out an emotional problem he was able to address. Ann, the health care assistant, says that she likes patients who need a lot of physical help. Jackie talks at length about caring for the person as a whole, taking into account all their needs. Although she does not use it at this point, ‘holistic care’ is a term she and other nurses use a lot.

  2. Ann says that she doesn't believe doctors understand what nurses actually do, although James believes that much has happened to change doctors’ narrow focus on disease. As a doctor, Dave is clear that nurses are vital. He singles out the emotional support that nurses give and reflects on the strains this brings. On the other hand, his examples seem to be about the nurse as ‘assistant’ to the doctor. On that basis, one might be inclined to agree with Ann. Notice though that the organisation of the work means that neither doctors nor nurses are well placed to observe fully the work of the other.

In the next activity you will listen to the final audio clip in this section, and hear something about how the ward feels from the receiving end. Susan is the patient. Seven years before, then in her early forties, she had a stroke and was nursed by Jackie, who at the time was a staff nurse. Susan, her husband Jack, and her grown-up children all knew that with a diagnosis of liver cancer Susan had only a short time to live. The week before our visit she had collapsed at home. She had been rushed into hospital where staff had been able to stabilise her condition. When I met her, she was cheerful and alert. She and Jack listened carefully to what I was trying to do and agreed that they would like to take part. Susan sounds lively and energetic on the clip. She and Jack were hoping that she would be back home in another week and said that they planned to ‘just take it from there’. Sadly, that was not to be. Susan did not leave Ward 29; about 10 days after my visit she lapsed into a coma and died.

Audio: click below to listen.

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Transcript: From the receiving end

How does health care look from the perspective of the hospital bed? Susan, a seriously ill patient on the ward, and Jack, her husband, reflect on the experiences they have had.

JACK
Bringing Susan into hospital. they said that she wouldn't see day out. So for the first four days, I were here twenty four homs a day. Just nipped home for odd hour, get some clean clothes, have a shave. Literally did everytlring for us there, fed us, coffee, well they nearly put a coffee machine at side of me. All I can say about the staff and such as that, helped my day along, and nights. There were always somebody there for you to talk to. The nurses, care assistants, even down to lady with't tea. She'd have a sit down, a chat or you could go and have a chat with her, if you wanted to get out of way while they were doing someut with Susan or. It's a tremendous ward and I think that, thing that makes it a tremendous ward is the people that work on it.
My brother were in here years and years ago, and then it were, the old style hospital where, matron used to walk around and, you know mean no there were no laughs or jokes or owt like that.
I'll do anything for Sue, and while ever she's fit I want her at home. After the care she gets when she comes in places like this, I don't get apprehensive when I've got to bring her in, because I know she's going to get good care, from no matter who looks after her. It's easier at home, because you can do things in your own time, can't you.
SUSAN
I'm a person that just very easily really. I suppose, more elderly people, they they do get frightened. You are more one to one at home, than what you are sort of in a ward, where there's a few nurses. Sort of got to know more or less who's who now. Like your pharmacist will come in and check your drugs, on a morning, and then you've got blood lady that comes to t:alce your blood.
(Susan talks to Phlebotonist)
SUSAN
Drop ... with a thin needle. LAUGH please, or she won't not be able to get a vein up, because I haven't got any ...
WOMAN
. . . straighten your arm for me a little bit. They normally t:ake it out of here Susan?
SUSAN
Yeah they have been doing yeah, over, you know, when they wanted it.
WOMAN
Erm.
SUSAN
But I've such got fine fine veins, they can never find them. Sometimes it runs, sometimes it doesn't.
WOMAN
Erm, sometimes it stops.
SUSAN
Yeah. Stops in mid stream.
WOMAN
Oh right now, oh we are lucky today.
SUSAN
Oh, thank goodness for that.
WOMAN
That's fine .... Just press firmly on there please for me keep your arm straight.
Thank you.
SUSAN
Thank you very much ... Done and dusted ...
SUSAN
And then you've got your nurses that'll come and do your blood pressure, and your temperature. And then another nurse might come and do your blood sugar. So you've got quite a few er doing sort of different things. But once you get to sort of know who's who, it don't bother me now. I know who's coming for what, that's alright by me. If it was somebody I didn't know I would ask them, I would ask them who are you and what have you come for.
They they do get to know you as you you are a person you are a name, you're not just a nwnber, that's laid in a bed like number - bed sixteen. You are an actual person.
I'm a very faddy eater, and I mean the hot meals some of them are very nice, some I just don't like what's on menu. So I get my husband to fetch me a sandwich in or a packet of crisps, or a chocolate biscuit Or one of nurses will even come down to shop for you. If you can't get to the shop they will actually come down to the shop for you, and get you ever they want, what you want.
(Susan talks to Ivy, her friend)
SUSAN
Dietician came other day, and talked about supplements that you can get, like if you haven't got a big appetite ....
IVY
Yeah.
SUSAN
They fetch them three or four times during day.
IVY
Have you had any yet?
SUSAN
No, because it talces a while to get into system and I'll have gone home by time mine gets through system.
IVY
Well that's ridiculous.
SUSAN
I know.
IVY
I think we aught to complain about it.
SUSAN
I'll have to ring him up and tell, take them home with me, in a big suitcase.
IVY
Well no I mean it's is ridiculous if you're in for a few days.
SUSAN
Well that's what I got told yesterday. Well I thought I would get them last night. But then when I asked lady in't kitchen she said no, they take a while to get through system, couple of days she said. So I don't lmow when I'll get them.
IVY
Are you going down for another en-endoscopy?
SUSAN
Yeah. So I won't be able to eat anything after midnight.
IVY
So is your appetite getting any better at all?
SUSAN
A little bit, I fancy someut right scrumptious to eat and I don't lmow what I want.
IVY
Excuse me, has this lady's supplements come up yet?
SUSAN
Er, well it's cream crackers and Rivitas and you lmow cake and what have you ...
WOMAN
Some scones up for this afternoon.
SUSAN
Is there?
WOMAN
Yeah for three o'clock.
IVY
No she just wondered if er you know, her supplements had come up ...
SUSAN
You know, I thought had come up for me oh. Okay then.
WOMAN
INAUDIBLE
SUSAN
Ay.
WOMAN
INAUDIBLE
SUSAN
Do you think so?
WOMAN
Yeah.
SUSAN
Right. (FADE DOWN)
JACK
They've been great, everything they've done they've explained it, and what it meant, and er I've all but admiration for them. I mean they brought Sue back more or less. She fought as well like, and that's a tremendous part of her character is that. She keeps me going as well. But er, like I say, I've just the admiration that well it oozes out of me, and my son and daughter.
It's hard for me and Sue, but it's ten times harder for them because, to know exactly, I mean they know exactly what the problem is and they know that before her time, Susan's going to die. But even in here they've been tremendous towards them. I mean it's not been doom and gloom. But you can't have doom and gloom you've got to be able to, have a giggle with somebody, just to take it away just to take that hurt away, and they've done that with them two, and they found it fantastic. And again that's all down to't personality of people who've who are there at tl1e time, and they can pick up on things like that.
SUSAN
I think you've got to ask. If you don't ask you don't get told. and I do like to ask, and I do like to know what's going on. It's my body so I want to know what they're putting in me, and why am I having this injection, and what is it for, and what is it going to do for me. Ifl want to know anything I shall go and ask.
Some doctors you get that'll stand and talk O\'e!" your head, they won't talk at you, they will talk between theirselves, and I don't like that, I like to be spoken to. So you just have to say excuse me, but I am sat here, and some do apologise, and think again. But I mean none of nurses, you don't get ignored by none oft nurses. But I've had no problems. I think they've realised, we need straight talking to, not going round comers, and giving all these fimcy names, because layman doesn't understand it. You want it in plain and simple tenns. So you can actually understand what they're talking about.
JACK
I think, they have to deal with so many people that doctors don't they. They're flitting backwards and forwards just like Susan said, a hundred mile an hour and sometimes I presume, I don't suppose they know that they're doing it, but all you've got to do is like anything else just got to er explain who you and tell them what you want to know, and they'll tell you. They won't go round no comers if you don't want them to.
SUSAN
I think you need somebody to listen to you, and have time to listen to you which the nurses do. The doctors might be that little bit more rushed about than the nurses, because their bleeps are going off, all things like that but er. They've really looked after me. They're not ntHSes and you're not a patient, you're a fiiend.
JACK
It's an awful thing for anybody to have to care in a situation like we have. I know we've got some good back up, so we're just going to talce very dy as it comes aren't we,yeah.
End transcript: From the receiving end
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Activity 4: Patient perspectives

0 hours 20 minutes

Listen to the audio clip. Jack speaks first, describing Susan's emergency admission. Then Susan talks to a friend who came to visit. Listen to the whole clip first, and jot down your first impressions. Next, read through the questions, and then play the scene again, noting down your answers.

  1. Jack and Susan have a great deal of praise for the care that they have received. What kinds of things do they value most?

  2. Alongside the praise, there are also hints of ways in which things can go wrong from a patient's point of view. What criticisms, for example, do they have of doctors? Are there any criticisms of nurses or of the nursing care they receive?

Discussion

  1. Jack couldn't praise the staff enough for the support that they gave him as he stayed by Susan's bedside. There was always someone ready to talk and he was particularly grateful for the way they would talk to his children too. Information is another need that he and Susan had. They wanted straight talking and they got it. Friendliness and informality were something Susan valued. She says that nurses have time; she feels she is a name not a number.

  2. Neither had any direct criticisms of the present doctors, but they were aware of what can go wrong. Some doctors, Susan says, talk over your head. She feels she is well able to challenge them and deal with it, but she observes that ‘you've got to ask’. Jack points out that doctors are so busy that perhaps they don't know they are doing this.

    It is hard to find any real criticism of the nurses. Susan does describe how confusing it can be with all the different people who come to your bedside – but she says she is a person who adjusts easily and is not afraid to ask. She and her visitor do complain about slowness in providing the diet supplements that she needs. Comparisons with home offer more clues to how hard it can be to adjust to the hospital. ‘You're more one to one at home’, says Susan (thinking perhaps of the fragmentation and specialisation when so many people come to attend to different things). ‘You can do things in your own time’, says Jack (thinking perhaps of the routines of the hospital day).

There are a number of published accounts of patient experiences in hospital which are more negative than the one you have been considering. Deborah Lupton, an Australian social scientist, who has gathered together and reviewed a number of published accounts, sees in them recurrent themes of helplessness and loss of control. She regards hospitals as settings where, from a patient point of view, confidence in your own knowledge and power is challenged and your sense of your self is diminished. She cites a number of accounts by people who have become ill, particularly by social scientists used to studying other settings and by doctors who become patients and are moved to observe what is happening to them. Here is just one example from Dr Oliver Sacks, a doctor who spent a long time in hospital as the result of a leg injury. Things he already knows take on a new significance from the other side of the fence:

One's own clothes are replaced by an anonymous white nightgown, one's wrist is clasped by an identification bracelet with a number. One becomes subject to institutional rules and regulations. One is no longer a free agent; one no longer has rights; one is no longer in the world at large. It is strictly analogous to becoming a prisoner, and humiliatingly reminiscent of one's first day at school. One is no longer a person – one is an inmate.

(Sacks, 1984, quoted in Lupton, 1994, p. 97)

The idea of ‘total institutions’, the depersonalisation, control and even abuse of patients that can occur are themes we take up at several points later in the course. For the moment, I shall return to the perspectives of staff as they try to provide treatment and cure alongside good continuity of care for the patient in hospital. The next section will examine in more depth the ways of working of the doctor, the nurse and the care assistant – how they define themselves in relation to others and what effect this has on the caring that is offered.

Key points

  • The work of many different people must be co-ordinated to care for health in a hospital setting.

  • Each occupational group tends to have a different work routine and a somewhat different outlook on care.

  • Patients, at a time of often great anxiety, face the challenge of adjusting to hospital routines and of understanding and participating in their care.

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