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based confessions of a newly
It would be easy to conclude, as I come to an end of my community placement, that the majority of people over the age of 75 have at least one venous leg ulcer. Mr O'Leary was no exception - in fact his was particularly painful and had so far resisted all attempts to heal. Like so many of the older folks in the community, he suffered the pain stoically. As he squelched his way into his living room for the daily bandage change, I glanced at the exudate stained leather of his shoes and the soggy mass of bandaging and was reminded of the embarrassment endured by these patients. Mr O'Leary smiled warmly, gently rolling his fingers in Parkinsonian rhythm as he enquired after my health in a soft Irish lilt. I desperately wanted to find a way to promote healing, and started searching for any hints in the research literature. It surprised me to find that until the 1990s,[link widoczny dla zalogowanych], although the UK Department of Health knew that a major proportion of community health expenditure went into treating leg ulcers,[link widoczny dla zalogowanych], it was not known how much that was, neither was the prevalence of leg ulcers known,[link widoczny dla zalogowanych], nor what treatments were being used and whether they worked. In fact little was known at all. A systematic review of available research was commissioned for the first time to try to answer these and other questions about leg ulcers. The results were not encouraging. The majority of the questions remained unanswered or where there were answers those answers were unclear. I realised that nursing research has a place in identifying further research needs as well as answering clinical questions. Fortunately what has been described as an 'evidence desert' spurred the NHS into funding a suite of systematic reviews of wound care in 1997. It is now widely accepted that compression bandaging is the main treatment for venous leg ulcers (Cullum et al 2001),[link widoczny dla zalogowanych], and that no conclusive evidence favouring any particular dressing beneath the compression bandaging has emerged (Palfreyman et al 2006). Unfortunately Mr O'Leary was not able to tolerate significant compression, and seldom remembered to elevate his legs to aid venous return. I had no Panacea to help him, and it was clear that we still need further research into this area. 'I'll see you at the same time tomorrow Mr O'Leary' I said having completed the dressing. What was my next visit? Oh yes, another venous leg ulcer.
It is hard to ignore the politics in nursing. Every time a qualified community nurse leaves, they are replaced by an untrained Health Care Assistant. What is going on here? I do not want to do HCAs down, as many of them do a superb job,[link widoczny dla zalogowanych], but if the job can be done as well by an HCA as a staff nurse,[link widoczny dla zalogowanych], then what is the point in spending three years studying and living on a student grant. Are the accountants taking over primary care? Do 'they' not realise that carrying out nursing interventions requires more than mechanistically following a care plan. A few days ago we all trooped to the hospital to listen to the senior manger explain how primary care is moving to a commissioner - provider model. Now having been a manager myself in a previous life, I have more sympathy than most for these unfortunate, overpaid individuals,[link widoczny dla zalogowanych], but their talk of corporate identity, metrics and strategic positioning was a real turnoff for us clinicians. "Tesco," lectured the speaker, "can sell holiday insurance, mobile phones, in fact almost anything." The bewildered nurses gazed at each other as the quagmire of mutual misunderstanding between speaker and audience widened. They had signed up to care for sick patients, were they to sell insurance? "We must all review our strategic marketing position,[link widoczny dla zalogowanych]," burbled the manager from another planet, but it was too late, the audience was lost. "We must leverage our core competencies to create a paradigm shift," she pleaded faintly. To be fair, she had little hope from the start. The majority of nurses, I believe, nurse because they care about patients, and have no wish to become business savvy; it is incompatible with their approach to patient care. If we must run like a business,[link widoczny dla zalogowanych], so be it, but nurses should focus on what they are trained for and do best, and accountants should allow them to do so.
This morning I am starting my placement in the community; working with district nurses in local rural villages. I am really looking forward to it, and it makes me realize that I have actually been a bit disappointed with some of my previous placements. Like any good nursing student,[link widoczny dla zalogowanych], I have reflected on this surge of renewed enthusiasm, and this is what my introspection has revealed; I have a horror of 'doctor's handmaid' nursing, and it appears that despite the modernisation of the nursing profession, there is still a fair bit of it going on. I feel that evidence based nursing has the potential to help guide the occupation away from this approach to become an independent, and mature profession. What excites me about district nursing is the long tradition of autonomy and independence in decision making. Perhaps I will miss the buzz of a busy ward, but I am relishing dealing with one patient at a time, seeing them in their true environment, and getting to know them as people. No doubt the reality will not turn out as I hope, but for the moment allow me to enjoy feeling positive, and to savour getting away from the interminable assignments, and get my suitably gloved and decontaminated hands dirty doing the real job of caring for people.
"He's on the throne," called Mrs Tonks from within the small cottage. "On the phone. How long will he be?" queried my mentor?". "Not the phone, the throne. He's on the commode" she laughing good naturedly. By the time we reached the living room, Mr Tonks was ensconced in his threadbare easy chair puffing like a steam train. His blue tinged hands reached anxiously for his nasal cannula, and he sucked deeply at the meagre 2 litres of domiciliary oxygen which oozed from the concentrator behind his chair. It was minutes before he was able to utter a word. He looked deadbeat, like he had just finished a marathon, rather than moved a few feet from the commode to his chair. I found this man's desperate struggle to breath after so little excursion shocking, and resolved to find out more about oxygen therapy. I started with a recent article in Nursing Standard about the use of domiciliary oxygen. I also found a Cochrane review that summarised the evidence base for domiciliary oxygen use.
The following day we visited another couple afflicted by respiratory failure. Mr Little and his wife lived in a beautiful village house overlooking a lake, but Mr Little had pulmonary fibrosis, a serious disease where the alveoli and lung tissues become damaged and scarred. Whilst we took a blood sample from Mr Little, his wife wheezed and coughed distressingly. "I have emphysema," she gasped. Mr little was getting used to using a permanent oxygen supply, and clear plastic pipes snaked across the plush carpets. He started telling me that he had been given conflicting advice on how long to use his oxygen each day. One nurse had thought that it should not be used for more than 15 hours per day, whilst the GP had suggested using it 24 hours per day. Did I know which was right? Pre-armed with my recent reading, I prepared to explain that research had shown that mortality in patients with severe hypoxaemia was reduced if oxygen was used for more than 15 hours per day,[link widoczny dla zalogowanych], but Mrs Little was to quick. "He won't know - he's only a student," she scolded her husband abruptly. I felt slighted. OK I was only a student, but I had been taught to read and appraise evidence, and to try to apply it in the real world, and here I was at last doing it for real, only to be told that knowledge was the preserve of the experienced. I felt pleased that I had looked at the research, and this empowered me to promote best practice, but was reminded that sometimes it is not what you know, but who you are that carries weight.
The 15 hours guideline emanates from the following research paper:
Medical Research Council (1981) Report of the Medical Research Council Working Party. Long-term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet 1981 (1) 681-5.
A broader review of the evidence base can be found in:-
Cranston JM, Crockett A,Moss J,[link widoczny dla zalogowanych], Alpers JH. (2005) Domiciliary oxygen for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD001744.
Dignity in practice is a hot topic at present. The media regularly publish horror stories of poor care, and it is drummed into us students that we must put dignity first when dealing with patients. Furthermore, the community practice where I am working is undertaking a dignity survey, canvassing patient's experiences of the district nursing service, so when my mentor and I visited elderly Mrs Potts, dignity in care was ringing in our ears. Mrs Potts had a sore bottom, and we had been asked to visit to assess it, and plan the care needed. We introduced ourselves, and explained why we had come. Mrs Potts was a little upset. Nurses from another practice had already visited that morning to take some blood,[link widoczny dla zalogowanych], had not said who they were, and had left the back door open when they left. She had made a complaint about them. Ah we thought, how lax of them. We would have expected better things from our fellow nurses. Perhaps we secretly felt slightly smug that our team were more professional. Mrs Potts was initially anxious about baring her bottom, so I discretely left the room whilst my mentor, after seeking permission, gently inspected the offending buttock. When we got up to go, Mrs Potts became distressed about some family issues, so we stayed and chatted to her for a while. I was impressed by my mentor's quiet caring attitude. We left promising to come again to check on her, and she thanked us for our efforts. As we departed, we were surprised to find that the door latch was jammed, and only some deft work with a pen allowed us to secure the door. "What a lovely lady,[link widoczny dla zalogowanych]," we commented to each other as we drove back to the office. A shock awaited us. Mrs Potts had just rung in to complain about a nurse and a student who had marched into her house,[link widoczny dla zalogowanych], and pulled down her pants without a word about who they were or why they were there. I was stunned. I could not imagine how my mentor could have treated her with more respect or kindness. It was fortunate that I was there to witness the good quality care that actually took place.
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