It isn’t always like this, with vast numbers of patients to a single nurse, but it has not been an uncommon experience for me. Hospitals have budgets to balance, though I do wonder if they’ve ever calculated the long-term costs. I hear that billions of pounds are set aside by government to provide compensation for legal cases brought against hospitals by patients and their families, but how much of that would be saved if we employed more staff and reduced workloads?
There would be less burnt-out nurses. There’d be less medical errors. There’d be less staff sick days, and greater retention of staff. There’d also be more time to spend with patients, and to do the simple but vital tasks of caring.
Mr Benson’s death was the beginning of the end for me. To my colleagues, I was unchanged, but inside I was angry at not being able to do the job to my satisfaction. Things finally came to a head one day when we had a staff shortage.
It was the afternoon shift, and again I had beds 1 to 16. The problem was that the regular nurse assistant had called in sick, and they couldn’t find a replacement. I bluntly refused to work until they found someone to help me. Claire promised to find me an assistant. So I got to work.
Out of 16 beds, 15 had patients in them, one of them a new admission.
Cubicle 1 – Mrs Wright
A confused elderly lady who thought she was in her own house. She thought her husband was still alive, but occasionally had lucid moments. She was complaining about the pain in her legs, and when she pulled back the covers, I was horrified to see two blue legs. They were the most ischaemic (poor blood supply) legs I’d ever seen. The pain must have been incredible. She had an infusion of heparin (to thin the blood) at the bedside, which was empty.
I promised to get her some analgesia, and get a new infusion of heparin.
It took three minutes to get the morphine ready, and another ten minutes to prepare another heparin infusion, but it took a further ten minutes before a nurse was available to come and check my preparations. By the time I eventually administered the morphine and replaced her infusion, Mrs Wright had been suffering for 25 minutes.
Cubicle 2 – Mr Lewis
Mr Lewis was a below knee amputee due to go home the next day, and wouldn’t need much assistance from me. Thank goodness.
Bay 1 – Male six-bedded bay
Bed 1 – A man recovering from bowel surgery and on a liquid only diet.
Bed 2 – A patient recovering from a large gastro-intestinal bleed. He was nil by mouth and on a drip.
Bed 3 – A patient on bed rest because of his leg ulcers, which had been grafted.
Bed 4 – A blocked bowel; nil by mouth, this patient had a tube running up his nose and into his stomach to drain out the contents, and a tube up his penis because the doctor wanted to accurately monitor the fluids going in and out.
Bed 5 – Next to him was a man who was in his second week post a partial resection of the pancreas because of cancer. It was only a matter of time before he died. The longest I had ever seen someone that I was directly involved with live after pancreatic surgery, was six weeks.
Bed 6 – Last, but not least, was a man recovering from a cholecystectomy, or in other words, he had had his gall bladder removed. The surgery is often done using the keyhole technique, but because of complications, in this case he was obese, the surgeon had to do things the old-fashioned way and open him up completely.
There was enough work in that one room alone to keep a registered nurse busy for the whole shift. But there was more.
Bay 2 – Female six-bedded bay
Bed 1 – Mrs Lawrence was 61 and one of the more lively patients. She was always looking out for the other patients in the room and was due to go home soon. She had had her gall bladder removed, and fortunately the keyhole technique had been successful.
Bed 2 – A 25-year-old woman recovering from an appendectomy. Fortunately, she was independent and would be going home in a day or two.
Bed 3 – A 53-year-old woman on intravenous antibiotics for cellulitis of her left calf. Also on bed rest until things got better.
Bed 4 – A blonde, 42-year-old, overweight woman with right upper abdominal pain, awaiting diagnosis. Experience told me this would be gall stones. She had all the risk factors: female, fair, fat and forty.
Bed 5 – A 70-year-old woman with leg ulcers, probably going to need vascular surgery at some point. In the meantime, she was on bed rest with daily leg dressings. Other than a commode, she shouldn’t be too much work.
Bed 6 – Located next to the window was Mrs Jackson. At 89 years old, she was the oldest patient in the room. She had been admitted because she had been neglected at the rest home she lived at. The result of that neglect was that she was left with bedsores on her sacrum, hips, elbows and heels. She needed hourly turning at the very minimum, half hourly if possible, but with my workload it was not always done on time.
I checked with Mrs Lawrence in bed 1 when Mrs Jackson was last turned.
‘I’m not sure, it must be at least an hour,’ she answered.
With no one to help me I did what I was not supposed to do. I lifted the tiny frame of Mrs Jackson off the bed and turned her on my own. It didn’t exactly hurt my back, but I could feel the muscles straining a little as I leant over her bed.
Cubicle 3 – The seriously ill room
Cubicle 3 was closest to the nurses’ station and as such, was reserved for the most unwell patients. It had two beds: Bed 1 – My only empty bed. I prayed it stayed that way.
Bed 2 – Mr Peters was 58 years old and had had a huge tumour removed from his abdomen. Surprisingly, the tumour turned out to be benign. Unfortunately, Mr Peters’s heart had taken a turn and he had developed chest pains. He was on a heart monitor, and an infusion of medicine to help keep the pain away.
‘It’s getting lonely in here,’ Mr Peters said to me as I walked in the room.
‘Well, I hope it stays that way,’ I replied.
Mr Peters chuckled at my reply. Incredibly, the bed next to Mr Peters had been empty for the last two days.
Claire walked into the room.
‘I’ve found you some help.’
She sounded cheerful. It seemed she had forgiven me for my outburst back in the staff room.
‘She’ll be here at five.’
The shift had started at two and it was now four. I should have walked out when I had the chance.
Five o’clock came around and my nurse assistant arrived.
Her name was Grace, and she looked as if she was barely 18. She was nervous. I discovered she was a first year nursing student.
I didn’t want to make Grace do anything out of her depth, so I had her check everyone’s blood pressure and other vitals.
I was angry, not at Grace, but at the people who had put her here. She was so naïve that she had no idea of the possible danger she could be putting herself in.
While she went to do my requests, I took ten minutes to eat a stale sandwich for dinner, before returning to answer Mr Peters’s call bell.
‘I’ve got some company at last,’ Mr Peters said, as I entered his room.
Lying in the bed next to him was a middle-aged man with a tube up his nose, a tube coming out of his penis, and an intravenous drip connected to his arm.
I went in search of Claire.
Claire explained that Mr Skove had a bowel obstruction, and was for surgery in the morning. When I asked her if there was anything in particular I needed to know, she told me to read his notes.
I found Mr Skove’s notes sitting in a disorganised pile in the nurses’ office. I sat and began to read, and the more I read the more worried I became. I went back out to talk to Claire.
‘We’ve got a problem!’
‘What’s wrong?’ she replied.
‘Did you know that Mr Skove was supposed to go to theatre tonight?’ I said.
She didn’t seem surprised.
‘Yes, and I was told they changed their plans and he would be going in the morning instead.’
She almost sounded smug with her thorough answer.
‘But do you know why they delayed surgery?’
She couldn’t admit that she didn’t know.
‘They’ve been busy in theatre and decided he could wait until morning.’
It wasn’t exactly a lie, but it wasn’t the truth either.
‘The reason he’s not in theatre now is that his haemoglobin is very low. They want to transfuse him three units of blood tonight.’
Claire made herself look even more foolish.
‘Of course, he’s for blood,’ she said, trying to sound as if she knew all along. ‘But he’s not urgent and they were happy to wait for morning.’
He was urgent, it even said so in the medical notes.
If you ever think things can’t get worse, then you’re sure to be proved wrong.
There was the slight problem of the blood not having been prescribed, and no paperwork in the notes indicating that a sample had been sent to the lab to be cross-matched.
The last thing Mr Skove needed was to think his doctor was incompetent. At the front desk I grabbed the phone.
‘Who are you calling?’ Claire asked me.
‘Er, the doctor,’ I replied.
‘Why?’
I was taken aback. Claire had never questioned why I wanted to use the phone or call a doctor.
‘The doctor forgot to prescribe the blood,’ I told her. ‘I don’t even know if the lab has done a cross-match.’
Claire grabbed the phone from my grasp and slammed it down on the desk.
‘We do not go chasing doctors,’ she ordered me. ‘It’s the doctor’s mistake.’
I felt as if I was having a bad dream; this just couldn’t be happening for real.
‘We’re far too busy to go chasing after doctors and fixing their mistakes,’ she added.
‘I can’t do that,’ I said with raised voice. ‘I can’t not call the doctor, knowing my patient urgently needs blood, knowing he urgently needs to go to theatre.’
Claire tried to speak, but I overrode her.
‘This is ridiculous. You can’t be serious.’
Claire got up from her seat and came around the desk.
‘Don’t dare speak to me like that again,’ she began, getting ready to let loose, but I interrupted her before her tirade could begin.
‘You’re angry at the way I’m talking? You should be worried about your patient not getting his transfusion and bloody well dying. Why can’t you see that?’
‘Into my office, now!’ Claire yelled. If looks could kill, I would have been struck dead then and there.
It was then I realised my time was up.
I had never before walked out of a job. My error was agreeing to work at all that shift. Over the years I had been working, as well as my time as a student, everyone, from tutors, managers and colleagues, had all said never to put yourself at risk. If it’s not a safe environment, don’t do it. In reality, nurses often work in less than ideal conditions, uncomplaining, but unhappy with the work environment we find ourselves in. It’s easier to plod along and stay quiet than to speak up.
There is a problem with speaking up: ironically, to speak up means
putting yourself at risk
. Management may say ‘Why didn’t you say something sooner?’ To which you will struggle to find an answer. Management will then look at how well you’ve done your job. They’ll see that you weren’t perfect. They’ll see that things were not always on time, and that some things may not have even been completed. They may even go back over your work records for the past few days, or even weeks, and find all the little faults you’ve made. In the end you could be the one who is negligent for not reporting a problem sooner.
‘I’m off home,’ I said to Claire. ‘This place is dangerous enough without you making it worse.’
With those last words, I turned my back and walked out.
As much as my decision to walk out was rash, or brave (still not sure which), it was the first time I’d been stopped from not only doing my job, but doing something that was vital for the health of the patient. Normally I’m trying to catch up, but there’s a huge difference between being overwhelmed with the workload, and actively ignoring a medical mistake.
I found out from my fellow nurses that my patient did get his blood that evening. But what if I hadn’t pointed out the error and the patient had died? Who would get the blame? The doctor for forgetting to prescribe it? Or the nurse who knew about it, and did nothing because it was the doctor’s lapse?
It was at this stage I decided my time in the UK was done. Within two weeks I flew back to New Zealand.
What goes through your head when you hear the words psychiatric patient? I wouldn’t be surprised if you came up with some rather unpleasant thoughts. I was just a student when I had my first glimpse into the world of the psychiatric patient and like most young males, I was comfortably ignorant – and happy to stay so – of things psychiatric. But, I didn’t have much choice – I had to graduate.
I remember very clearly my introduction to Waverly House. It was in my third and final year of training, and this was to be my last placement before my final exams.
As I drove to my first shift, I thought I must have made some mistake. I was in a rather affluent neighbourhood. The houses were big and modern, though nearly all had solid, high protective fences. I wondered if this was because they knew they had a madhouse in their midst. I’d seen enough movies where the psychopathic killer was standing outside the window peering in at a helpless, attractive and soon-to-be-next victim. Obviously these residents had as well.
I missed my destination completely, driving right past. I wasn’t expecting the place to be posted with a big sign saying crazies live here, but I thought that somehow it would stand out from the rest. Instead, I found a house just like the others, with a high, solid looking fence, presumably to keep everyone
in
.
Standing on the doorstep, with little idea what to expect, thoughts like would I be safe? or would they follow me home? ran through my head, I imagined someone suddenly opening the door and thrusting their face right up to mine, with eyes bulging, asking what I wanted. The door did open suddenly.
‘Ah you must be my student nurse; come in, the kettle has just boiled.’
I was hustled inside and to the kitchen by a tiny little woman who came up to my shoulder. Far from the welcome I had been expecting, I felt stupid for having let my imagination get carried away. She introduced herself as Josie Jones.
The psychiatric halfway house was a place where people with problems could go to spend their day. They could sit around drinking tea, playing pool and join in organised outings run by the two women who worked there. The women were trained nurses, with many years of psychiatric experience behind them. As well as providing a place for people to hang out, they offered counselling and provided a community monitoring service for the local hospital psychiatric unit. They could see who was deteriorating, or not taking medicines, and refer patients to the psychiatrist.
I was next introduced to the other nurse who worked there, Mrs Kelly Scott, and was again surprised to find her easily in her early fifties.
I was wondering where the muscle was around this place – surely they needed the use of a strong man occasionally, to control those patients that became violent. Mrs Scott led me to the lounge where I met Peter, Ben, James and Allan; all local users of the house.
They got up out of their seats to shake my hand and soon had me ensconced in a small circle and Mrs Scott decided it was time to leave.
‘I’m sure you boys will have plenty to talk about. I’ll catch up with you later.’
I am sure this was a strategy that was used often – leave the new student and see if they sink or swim.
What exactly does one say to a group of psychiatric patients?
‘What brings you here?’ certainly didn’t seem appropriate, nor did, ‘How are you?’
Thankfully, James took the lead and instead asked me what
I
was doing there. I was wondering that myself. Before I could think of a safe answer, they started laughing. The beggars were having a joke at my expense.
Allan invited me to the pool room and so our small contingent headed upstairs. The pool room was to turn into the most interesting room in the building. I was told that I would be teamed up with Peter against James and Allan.
As the game got underway Peter began to talk about himself.
‘I have schizophrenia, so I don’t usually need a partner.’
Again, there was a round of chuckles from the rest of the boys. Peter then explained that he was always hearing voices, he was never alone. He could cope with the voices, as long as they were not too loud and as long as they were not saying anything bad. They didn’t seem to affect his pool playing as he sank two balls in a row.
When Allan went to take a shot, he said that he had bipolar disorder, but his medicine was working well at the moment. He sank two balls. When it was James’s turn to shoot, he said that he had been an alcoholic and it had affected his brain. He said he was not as sharp as he used to be, as he sank three balls. It seemed the pool table acted almost like some sort of therapy couch, as it gave them an excuse to talk, although I was a bit taken aback at how open and blunt they were. It was also becoming obvious that I would never beat any of them at pool.
Their openness gave me a chance to ask some questions of my own; the first of which was how they could be so open about their problems with a complete stranger.
‘We’re not all open,’ Peter said. ‘This is my life. I can either get on with it or spend it trying to hide my problems. That can get a bit tiring.’
Unlike physical medical conditions where there is sometimes a cure, a course of antibiotics or even surgery to solve a problem, mental illness often has no cure.
‘But what about your medicine?’ I asked.
Peter said his medicine helped reduce the volume and violence of his voices, but they were always there and always would be. He added that at least he didn’t look like he had a problem. Surprisingly, this drew another round of laughter.
Aside from joking, I had never before given serious thought as to what a psychiatric patient might look like, but I swear Peter looked like one. He was a small, emaciated looking fellow with big bulging eyes and a large forehead, accentuated by his baldness. He had scraggly, dirty looking shoulder-length hair and an equally scraggly goatee. He was the sort of person whom if you saw in the street, you would make sure to leave a wide berth.
Feeling emboldened by such openness, I asked Peter when he first knew he had a problem. His bulging eyes locked on to mine, and he just stared and did not say a word. I was taken aback, thinking I’d offended him.
When he finally did speak, he spoke with an intensity that made everyone look up and pay attention.
‘I knew I had a problem when I found myself standing at the foot of my parents’ bed one night with a kitchen knife in my hand.’
I felt a shiver go down my spine. The laughter we had shared earlier now seemed absurd in the context of such a very sobering comment. The lads were still all smiles, but I could feel their eyes looking at me, questioning me, wondering how I would react to such a comment.
‘Ah, so what happened?’ I asked nervously.
He shrugged his shoulders.
‘They’re fine,’ he said, ‘I didn’t kill them . . . yet.’
The rest of the group burst into another round of laughter. I tried to join in, as I felt that it was expected of me, but I felt lost. I couldn’t figure out what was real and what was not; I guess I must be really fitting in.
I asked him what stopped him and he leant forward, his face close to mine. He had caught me off guard and I didn’t have a chance to move away.
‘It’s as if I had a moment of truth, as if God had given me an instant of clarity, another chance, at the last second.’
It certainly gave me some perspective on all the joking around that had gone on before.
Ben said he suffered from depression and had recently been discharged from hospital, although it wasn’t his first time there. He added that he also got a bit excited at times.
‘The doctor says I’ve got a mild case of bipolar disorder, but I’m not so sure,’ he said.
‘Why do you say that?’ I asked reluctantly.
My mind still had an image of Peter standing with a knife at the foot of his parents’ bed and I was worried what horror stories Ben had to share.
‘Well, it sure doesn’t seem minor to me, because I’ve lost my job, my wife has left me and the only friends I have left are the people in this room.’
He then explained that he blamed everything on one night out on the town several years ago, when he had dressed in women’s underwear and gone to the local nightclub, and ended up being arrested by the police.
Many of the people here were like Ben, because they had lost their friends, their wives and children and had nowhere else to go. None of the people here worked, because no employer would take them on. This was their world now and these were their friends.