I sit in bed for ten minutes, struggling to wake up. It’s still dark outside and will stay dark for at least another two and a half hours. I stumble in the darkness to the bathroom, willing myself to put the light on which stings my eyes and they start to adjust.
The kitten saunters over and meows for cuddles while I’m getting washed, brushed, and scrubbed. I have everything I need laid out and getting toasty warm on the bathroom towel rail and get dressed into my starched tunic dress and thick tights. Making sure not to disturb him, I give David a quick peck on the cheek, envious his alarm won’t go off until I’m well into my handover at the hospital.
Closing the door silently, the kitten settles on the sofa as I get all my books and belongings together. Putting my ugly shoes on, I check outside and am relieved to see the car isn’t frosted over.
The car is freezing and take a few turns of the ignition to start. Whacking the heaters up to full, I start the drive to the hospital, hoping there’s no traffic. I catch the start of Chris Moyles’ show on Radio X and lose myself in his stories of music and weight loss and general hilarity. As the 07:00 news bulletin starts I hit traffic coming into the hospital as other nurses, students, doctors and health care professionals arrive from near and far.
The car park is usually so busy it’s impossible to park anywhere (which means parking on a side road somewhere and getting the bus in) but at this hour there are a handful of coveted spaces left. With trains and buses running a limited schedule I contemplate asking the council to revise their timetables, but it’s a futile, fleeting thought.
The car is so warm now, and again I will myself to open the door and let freezing the air in. After a brisk walk into the hospital, I stop at the staff showers and restrooms to put on a very light layer of makeup. Hair up in a swishing ponytail, I attach my fob watch and name badge and make my way to the ward.
The last few shifts have been a cacophony of chaos with patients being crammed into ever space we’ve had in the ward. There’s been no dignity for people as they’re sat discussing their private medical and social issues within earshot of everyone else. It’s been demoralising for everyone.
Going into each shift requires teamwork like no other. Walking through the ward to the staff huddle area it’s easy to get a sense of the goings-on of the night before. Sometimes, the ward smells like urine and opened bowels, which means the nurses and HCAs have been busy with patients needing their full attention and care rounds have been delayed. I look at the night staff and see their tired faces frowned in concentration as they prepare to hand over the night’s goings-on.
Handover begins in the now-empty relative’s room (this had housed two patients a few nights prior to today) with the nurse in charge of the night shift giving us a low-down on what’s happened as well as any team news, such as training updates. A few patients have been discharged and forgotten their medication so we’re all warned to check and double check before they leave they have everything. We’re reminded to document everything that happens accurately and on time. We have several patients waiting for beds and these notes are scribbled down as the handover sheet has run out of room.
We’re also told about patients who are scoring above 5 on the National Early Warning Score framework, those requiring end of life care, any falls during the night and infections that need to be contained. Today, we also have a patient who received a double lung transplant, so reverse isolation is in place meaning we protect the patient from the outside as much as possible.
With all that out of the way, we get given our assigned bays and start patient-by-patient handovers. This includes who the person is, why they came in, what their previous medical history is, what needs to happen today and when they’re likely to be discharged.
Having our precious handover sheets filled with all the information we need, we then start to see each patient one by one. Some nurses start by saying hello and helping patients who need assistance sit up. Others like to dive right in and get started with med rounds. Today, we’re doing the latter.
My mentor gathers all the drug charts, and we check each patient’s name, any allergies, and the medications due that morning. The pharmacist has scribbled a few notes in green with amends to the chart, so we go by her changes. The nurse says that some medications can’t be administered if heart rates are too low, or blood pressure is too low, so we check these before we administer them.
I slowly check the time their meds are due, the name of the drug, and the amount of medication to ensure the dose is correct. Some are straightforward, others will need controlled drugs which are locked away (morphine, oxycodone etc), others need IV (usually as a bolus, but sometimes as a drip) and others need subcutaneous or intramuscular injections which will be prepared after the main drug run.
I’m slow as I check, recheck and check again, only signing the chart when my mentor is confident the pill has been swallowed. Some patients refuse their medication, so we make a note of this. Others will use their own meds, so again, we chart this all.
We then assist each patient who has limited mobility with a body check, to make sure they aren’t at risk of developing a painful, and sometimes fatal, pressure sore.
We’ll also hand over to the senior sister or nurse in charge for the MDT (multi-disciplinary team) meeting. They will relay all details of the patient to the doctors, consultants, registrars as well as occupational therapists and physiotherapists. Social services will also be involved at this stage as well as safeguarding teams.
After spending the first few hours on medication rounds and checking everyone’s immediate needs, we discover we’re first in line for breaks. While we’re in the staff room enjoying a much-needed coffee, the Health Care Assistant (HCA) will monitor each patient and ensure they have everything needed, including helping with breakfast time.
We, in the meantime and depending on the morning we’ve had, either chat about the latest goings-on, or sit in silence relishing the peace.
It’s the last time we’ll sit down until lunch, and we’re called away early as a patient needs to be admitted to the last empty corner of our bay.
By the time breaks are over, we’re semi-refreshed and ready to help with any leftover tasks for the morning and admit the new patient who’s been sat int he ambulance bay for hours. The HCA will start washing patients who need assistance, so we’ll assist making sure everyone is fresh and clean. We don’t have time to assist patients in the shower unless they are fully independent, so anyone who’s a little frail has to make do with a bowl of hot water and fresh wipes.
During the morning we’ll catch up on the mounds of paperwork that need filing, take calls from family and friends wanting to know how their relative is doing, and assist with any requests, such as PRN (as required) pain medications. We also make sure we complete comfort rounds every two hours, repositioning people if they’re bed-bound and ensuring they have everything needed. If they are in pain this will be documented.
The doctors and consultants will reassess each patient. We’ll help those who are medically fit for discharge get ready for home or transfer to other wards, and we’ll welcome new admissions.
Another half hour of peace and quiet (hopefully). This time we’re not disturbed, and we all catch our breaths after a hectic morning.
We’ll check each patient’s drug chart and see if they have any IVs that have been prescribed during the doctor’s rounds. It’s still manic as patients have their incontinence pads changed and are helped to the loo, we continue with care rounds and also our documentation.
At some point we’ll sit down and the nurse I’m working with will pick a few key skills for me to try today. Today, we’re going to be practising subcut injections and she will sign me off on assisting a patient to eat. Together we check our handover sheet and see that a lady in a side room is visually impaired and needs assistance at lunch.
When lunch arrives, I ask the patient if she would like help, and I ask her how much help she would like. I don’t want to assume the lady is totally blind, but also want to reassure her I have time to sit and help if she needs it. I place her tray in front of her and move her hands to where each item is, her fork is here, her knife here, her water is here. I explain she has chicken breast with potatoes and veg, and she asks if I can load up each fork for her, and she’ll take the fork and eat it herself.
We have a lovely lunch, like two friends out for dinner. After she tells me she’s full I move her tray away and see if she needs anything else. She has a catheter so take a urine output measurement discretely and note the volume on her chart.
Our meal is over and a call bell signals a patient int he side room needs something. I rush over, to find a gentlement complaining about the tea. I listen to his gripes as he moans about the state of the NHS, all the while willing myself to keep my mouth shut. I head over to the kitchen to make him a new one. Still, it’s not good enough, and I laughingly joke to the man at least he won’t have a £250,000 bill to pay at the end of his stay.
Skills and reflection
I then find my nurse and explain what I’ve done so far. We talk about why we do things they way they’re done. It’s never enough to just say ‘that’s how we’ve always done it’ as nurses need evidence, a firm and concrete reason why we do things. We have a red tray, for example, as a stimulant for the patient as well as a warning for us they may need help. We orient a visually impaired person to their food as they may be fully capable of eating independently.
She signs off my book, and then we talk about injections, techniques, and a little bit about pharmacology. After a quick chat, we’re off again with care rounds, medications and discharges and transfers. The jobs that never end.
Several patients who were waiting in the corridors outside have been allocated beds as we try to move people elsewherein the hospital.
As patients enjoy their meals, we make the most of the time to have our own dinner. Swathes of people are leaving their 9-5 jobs right now, and I’m envious of them. We still have around four hours to go.
Most drugs are prescribed for 8am and then 6pm, so this is our busiest round. And this is when we start our injections. Most people in hospital who are limited in their movement (including women who’ve had a caesarian section) will be prescribed an injection called Clexane. This is injected 5cm away from the navel, in the skin of the lower right or left quadrant. I watch my nurse prepare the area and administer the injection, feeling a lot like a baby T-Rex watching its mother.
Now, it’s my turn. I ask the patient if she minds me injecting her and she agrees. I crouch down as my nurse watches, and I explain to the patient what the injection is for and where it’s administered. Before I’ve finished the patient is pulling down her gown – she’s the pro here! I speak to the nurse now, explaining I need to inject away from the belly button. I choose the area and pinch it, my hands shaking and sweating in my blue gloves. The nurse says that’s the right area. I get the injection ready and in one quick motion, pierce the skin reaching the fat between the skin and muscle.
With the bolus delivered, I ask the lady how that was – she had no idea it was all over and complimented my technique. Now, just eight more to go.
With dinner over and patients all settled, we help them into new gowns and get their beds ready. Some prefer to sit up in their chairs a bit longer, others are grateful for the chance to get into a bed to ease their pains. Medications are over and the nurse and I take the time to catch up on paperwork. I know I slow her down, so I apologise. But she tells me never to be sorry. She tells me of times she’s almost made a fatal mistake through rushing, and that all nurses need that caution we have as students to make sure their patients are looked after safely.
The night shift team of nurses and HCAs arrive and we welcome them with smiles – it’s been a very busy, but enjoyable day. They all wander over to the huddle and we do our last few checks on patients. Everyone has been allocated a bed, but this has meant consultants pushing people to discharge sooner than we’d like.
When they’ve been briefed, we hand over the day’s events in the same way, with patients names, what they were admitted for, what their history is, any news of the day.
It takes a good half hour to get them up to speed – so much will have changed in a day, and many people would have left to go home or other wards as their healthcare journey continue.
It’s ten past home time, but handover has taken slightly longer than we thought. As we finish up, the night staff gets ready for their first medication round and we dispose of our handover sheets. These are never taken out of the hospital, given the sensitive data scribbled on them.
By the time I get to the car, it’s frozen over. I realise I used the last of the de-icer the other day and curse myself for not getting some. With the car running, I fumble around for the scraper and remove as much ice as I can before my hands start to go numb. With the heater on and the car starting warm up, I start the journey home, tired but glad I’ve learnt a new skill.
David’s been home for hours now and has a kiss and cuddle, as well as leftovers, waiting for me. I get all my clothes ready for tomorrow morning, set my alarm and wolf down my meal.
No time for tv or to wind down, I’m exhausted. I can’t think, I can’t speak. I go to sleep mentally replaying everything that happened during the day in my head, wondering how much will have changed by tomorrow.