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. DOCTORMy name's doctor .... I'm the doctor that works on the ward, alright. How are you doing?MANWell 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.DOCTORINAUDIBLEWOMANPardon.DOCTORNifedopin.JACKIEIs that what it is?DOCTORYeah.WOMANOh right. Well it's a really common one. INAUDIBLEDOCTORIt'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 INAUDIBLEJACKIEWell 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. Activity 1: The ward sister's day010Listen 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.
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. Activity 2: Contrasting routines of staff on the ward020Listen 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.
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.JAMESThe 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 INAUDIBLEANNE 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. LAUGHJACKIE 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. JACKIEToday?ANNEYeah.JACKIEWe'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.JACKIEI 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." Activity 3: Different approaches to care?030Now 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.