https://vivbennett.blog.gov.uk/2014/06/24/district-nursing-david-foster/

Experiences from the Frontline - District Nursing - David Foster

VisDavid Foster portraitit to Liz Alderton, district nurse North East London NHS Foundation Trust

She’s as fit as a whippet. I’m not. She can run a marathon. I can run a bath. She’s a district nurse, a Queen’s Nurse and an extraordinary person. She is Liz Alderton. She would argue about the “extraordinary” bit because she thinks she’s just doing the job - may be so, but with extraordinary skill, passion and commitment. And she is like many thousands of others who, unsung and often unnoticed, are nursing patients with complex needs and often in challenging circumstances in their own homes day in day out.

We are in Harold Hill, near Romford , and Liz works for North East London NHS Foundation Trust. She waves eagerly from her car as she picks me up and instantly I can see, even at this time of the morning, this is a woman with boundless energy and enthusiasm for life, running and nursing. It’s obvious I’m in for a whirlwind morning and it’s going to be hard to keep up.   But don’t get the impression she’s stuck in top gear; her sensitive ability to change her pace, give people quality time and be thorough is remarkable.

Perhaps not surprisingly the day starts with giving insulin to people with diabetes. We had to catch Eileen[1] before the transport came to collect her to go to a hospital appointment for her foot care. She has a learning disability and cannot give her own insulin. Liz washed and dried her hands and prepared her kit to test Eileen’s blood sugar and then give the injection. Eileen prepared herself by holding out her hand for a finger to be stabbed and hitching up her jumper for the injection. This was a clearly choreographed routine which didn’t need much conversation. My attempt to ask Eileen about her hospital appointment was drowned out by the weather forecast on the TV and probably filtered out by her reluctance to engage. I stood awkwardly watching the care and precision Liz took over something so routine. I probably should have paid more attention to the weather forecast: it looked like intermittent, heavy rain would dominate the day and there was I with no coat and no brolly. Oh well. Liz checked with Eileen what she was going to have for breakfast and made sure they both had the same understanding about what would happen at the hospital later in the morning. A quick and skilful chat which engaged Eileen more than the TV and left Liz being assured she knew what to expect tomorrow.

Malcolm was also due his insulin and was in a neighbouring flat, but he wouldn’t have welcomed being visited so early so we dashed to the office. There I met some of the team while Liz checked on phone messages and spoke to the duty triage nurse. Bernie, Lee, Marie, Sue and student nurse Craig were all keen to describe their priorities for the day and to be sure I understood the complexities of their work. Anyone who has the preconceived idea that district nursing is predominantly a leg ulcer service is absolutely wrong. Liz had two women on her morning’s list who needed leg ulcer dressings but the others were very varied. And that’s not to diminish the importance of dressing and healing leg ulcers which district nurses are superbly expert at, but there is so much more.

Back in the car to visit Malcolm, Liz explained the triage system. It was introduced only a few weeks ago and is already saving time and streamlining visits. Although it consumes the time and expertise of an experienced district nurse back at base, it means those out seeing their patients are not constantly interrupted by phone calls and ever lengthening “to do” lists. The triage nurse can often answer questions from patients to resolve problems and allay anxieties very quickly. GPs and other colleagues also use the service and it is already beneficial in streamlining arrangements for discharge from hospital because the triage nurse can accept referrals, order equipment, arrange support from hospices or specialist nurses promptly rather than leaving such tasks to the afternoon when the district nurses return from their caseload visits. The triage nurse is now taking 30-40 calls each morning which would otherwise have interrupted the district nurses giving direct patient care.

When we got to his flat, Liz had to let us in. Although Malcolm was ready for his insulin he didn’t move from his bed for his blood test or insulin. His mental health problems rendered him fairly uncommunicative and he looked extremely depressed. We had a quick chat about the weather as he stared out of his bedroom window at the leaden sky. Liz went to his kitchen to prepare the insulin. She gelled her hands. As I was pondering why she didn’t wash them I could see using gel was the most hygienic option. The hand towel was best left lying on the draining board: practical, sensible and non-judgemental. Malcolm needed a quick reminder about eating his breakfast and we were off.

In the flat opposite was Nancy. She couldn’t hear us at the door so the home warden let us in. The air was eye tinglingly heavy with the fragrance of fags. And there Nancy sat on her sofa, wafer thin, toothless and well into her 80s with a graze on her shin. She’d bumped it on her walking frame and her fragile skin had torn. It was a straightforward wound but because of her poor circulation was in danger of not healing quickly. Was this a moment for a health promoting, smoking cessation chat? No. No point. What significant difference would it make to coax Nancy into giving up one of her only pleasures? What Liz did do was to dress the wound with dexterity, making a judgement about which dressing would be best and making sure in her notes whoever dressed it next understood the rationale for the choice of dressing. All the time she chatted to Nancy weaving the conversation round to how to help the wound healing, how to avoid banging her shin again and giving her choices about how best to bandage her leg.

We went from Nancy’s grazed leg to Maureen’s blistered feet by way of a drenching in torrential rain. Maureen had the front door wide open to get a blast of fresh air through the house which meant we didn’t have to hang around on the doorstep getting wetter. Although Liz prepared me to expect the blistering I didn’t expect them to be so extensive and painful. And the cause was unexpected: it was a reaction to a bone marrow transplant. Graft versus host disease is something I haven’t come across frequently. Maureen was remarkably stoical given her circumstances, her cheerful face rotund from steroids.   I suppose most remarkable for me was her positive outlook on life. She’s in her mid-fifties and has an easy relationship with Liz, but of course their real challenge was not about the blisters. That might have been the immediate problem, but Liz’s mind was racing towards how she and Maureen might handle an uncertain future. The graft versus host disease might be manifesting itself as blistering but it could easily be heralding an unsuccessful battle against Maureen’s underlying disease. And with a gentle touch and a quiet comment Liz could shift from friendly banter to opening up the most difficult conversations.

Her artistry at crafting conversations was as profoundly an important nursing skill as all her dexterity with dressings. And this wasn’t the only example of her ability to absorb and deliver awkward messages.

So when we went next to a young pregnant woman with a broken leg it shouldn’t have come as any surprise that we weren’t just going to give her an anticoagulant. One of Liz’s colleagues had visited previously and had raised concerns about her parenting skills. On that occasion the woman’s first child, now three and with a degree of autism, was splashing away in the bath with two closed doors between him and his mum. Was this usual? Was this a safeguarding issue? In the time it took to give the Clexane Liz had steered the conversation to bath time and the youngster’s apparent demand to bathe alone behind closed doors. By gently using her own parenting experience she was able to get the message across that bath times should be supervised. Mum assured us that really was the case. Dad was also home and joined in the conversation. I sensed the penny drop. His realisation of the risk and reality of what Liz was saying was starting to outweigh his little boy’s bathroom requests. I was stunned at how this conversation went – smooth, skilful, successful.

And from the beginning of life we sped to the end of life to address some really difficult palliative care issues. So, already having marvelled at Liz’s verbal agility she now gives me a master class in talking about death and dying. Not in a confrontational way, but honestly and fearlessly.

Mrs Murdoch is dying. She has struggled with a brain tumour and its effects for many years but now needs palliative care. Her life is bound to be short but it’s not clear how short. Her husband is her carer and can no longer cope. The physical demands are one thing: Mrs Murdoch’s balance is impaired and it’s extremely difficult for her to move about independently and it’s really awkward to get to the toilet in the night. But the emotional toll is really showing in Mr Murdoch. He is doing his best, and his best is really impressive – but it’s not good enough for him and it’s not good enough for his family. They are putting him under a lot of pressure to transfer Mrs Murdoch into a nursing home for her end of life care. And what does Mrs Murdoch want? Perhaps not surprisingly she wants what he wants. Liz and I are sitting on the sofa with Mrs Murdoch between us. Liz holds her hand. Mr Murdoch is in an easy chair and can hold the three of us in his imploring gaze. I want to hold my breath. This is going to be hard. What will Liz say? Well, initially nothing. Her purposeful listening is powerful. It would be so easy to take control and tell them what is going to happen, but she doesn’t. Her opening gambit is reflective, clearly showing she has understood the complex dynamics of this situation. And then she outlines the choices. It needn’t be the nursing home option straight away. What about an assessment by an occupational therapist to see if Mrs Murdoch’s movements around the house could be made easier? How about a night nursing service to take away the strain of Mr Murdoch’s interrupted sleep? How about carers four times a day to reduce the burden of a Mr Murdoch having to give all Mrs Murdoch’s care? This is tense, it can’t be rushed. Liz could perhaps predict the outcome of the conversation, but it’s not for her to decide. The choices and final decisions rest with the couple who have been married 51 years. Liz’s comprehensive assessment was fully documented: the Murdochs’ decision was fully supported and Liz put the wheels in motion. I breathed a sigh of relief. They had got where they wanted. Liz had simultaneously walked a tightrope and through a minefield and I was glad it wasn’t me doing the deal – my experience of running an intensive care unit suddenly seemed very straightforward in comparison.

These are six of the nine patients we saw in four hours. An extraordinarily intense and complex caseload with a variety I had not expected. Being a Queen’s Nurse Liz has impeccable credentials as a district nurse as her award from the Queen’s Nursing Institute testifies. She is surrounded by a talented team, supportive managers and is enthusiastic about all her patients, regardless of their challenges and circumstances. I hesitate to say she is exceptional because, for all the superb care she gave in this one morning, she is one of many being equally exceptional every day of the year caring for some very vulnerable people in their own homes. For me, Liz exemplified real nursing at its best.

If you are interested in adding value to your district nursing role and becoming a Queen’s Nurse please look at http://www.qni.org.uk/

David Foster is the Deputy Director of Nursing and Midwifery Advisor at the Department of Health

[1] All the patients’ names have been changed.

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