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.
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.
Activity 1: The ward sister's day
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.
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.
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.
Transcript: Dave, a senior registrar in medicine.
Now you'll hear from Dave, a senior registrar in medicine.
Activity 2: Contrasting routines of staff on the ward
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.
What are the main differences in the daily routines of the three speakers you have now heard?
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.
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.
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.
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.
Activity 3: Different approaches to care?
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.
Do the speakers feel there are real differences in how they relate to patients?
Do they all value each other's work equally?
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.
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.
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.
Activity 4: Patient perspectives
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.
Jack and Susan have a great deal of praise for the care that they have received. What kinds of things do they value most?
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?
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.
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.
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.