“I might forget names, sometimes faces, but I never forget a front door” said Liz Alderton with authority. I believed her as I stood behind her as she rapped on number 17. I was shadowing Liz as she went through her caseload of extremely varied patients in Harold Hill near Romford with energy, enthusiasm and diligence. A district nurse and a Queen’s Nurse Liz’s credentials weren’t in question but before the door swung open, her memory was. We had come to visit Mr Hawkins[i]; his name wasn’t familiar to Liz, although the front door was. “I’m sure I’ve been here before, probably about two years ago” she expanded. “I think it was to give catheter care to an elderly man after a stroke. He had a much younger wife. She did a lot of care for him at the end of his life and it all became a real strain”. Perhaps the flat had changed hands I mused. It hadn’t. The door was opened vigorously and resentfully and there stood Dawn. Her eyes narrowed and her jaw clenched as she recognised the lithe and blue uniformed nurse. As I witnessed this scene over Liz’s right shoulder, I couldn’t decide whether Dawn was about to deliver a head-butt or crumble into tears. It was neither, but the atmosphere for a few seconds was really tense. Liz disarmed Dawn by rapidly opening the conversation and, in recognition of her previous visits, warmly recounted that she recognised the front door and Dawn but that she had come to see Mr Hawkins. “That’s Dad” Dawn said. So, having cared for her husband in the last months of his life, Dawn was now confronted with caring for her father in his decline. From the referral letter Liz knew this man had prostate cancer which had been discovered late and, despite plans for chemo and radiotherapy, his life expectancy was likely to be short. This was a first visit so Liz was responsible for the extensive assessment needed to address Mr Hawkins’ nursing and social needs.
Dawn wasn’t expecting Liz. All the arrangements had been made with Mr Hawkins on his mobile phone, so although Liz had rung ahead and left a voicemail message it hadn’t been picked up. No wonder there was a frisson of aggravation towards Liz disrupting her morning and what’s more she’d brought some bloke in a suit with her. Liz explained the reason for her visit and introduced me. Dawn conceded we had better come in, “but the place is a mess” she said. “I was going to tidy up, but …” her voice trailed off. Frankly, no further explanation was needed. It would have taken a month of Sundays to bring any order to this chaos of clothes, bulging plastic bags and goodness what else strewn about every surface and most of the floor. It was clear Dawn had other priorities. I absorbed the scene and tried not to be judgemental.
We picked our way to the sitting room and Liz was introduced to Mr Hawkins. He was stretched the length of the sofa. His thick, grey hair was dishevelled, his shirt was completely undone and his baggy underpants not quite preserving his modesty. He had no doubt cast his blanket aside because he was too hot. As Liz crouched beside him to introduce us, all I could really see was the landscape of pale flesh undulating over the contours of his prominent bones – his cheeks, his ribs, his hips, his knees. I was shocked that this was a first visit for someone so skeletal, so obviously ill.
The assessment would take about an hour. Liz had nowhere to sit so dumped her kit bag on the floor and used it as a stool next to the sofa. I was left standing awkwardly on one of the few bare patches of carpet. Liz looked up at me with a sympathetic gaze knowing there was no option. Dawn sat opposite her father on the only chair. She spoke little. Her priority was to get the birthday cards to her father’s twin sisters written. She had no table, but used the ironing board as her desk.
As Liz began her assessment I realised that Mr Hawkins was a stubborn man who would make his own choices. He might nod and grunt in agreement, but in reality he would do what he wanted and do it his way. My mind was buzzing with unspoken scenarios: what if?, could we? My judgemental, paternalistic thoughts faded as Liz embarked on the assessment. She might have a form to fill in, but her skill at eliciting meaningful answers was masterful and not reliant on the template in front of her.
For an awkward moment, Liz broached the subject of Mr Hawkins’ diagnosis. Both he and his daughter knew he had prostate cancer, but neither seemed to know about the spread to his bones. It was clear to Liz from the scan results in the referral letter that the cancer had spread, but neither Mr Hawkins nor his daughter had been told. Liz re-read her information silently. Dawn volunteered that they were due to go back to the hospital in a couple of days to get the scan results. Liz hadn’t put her foot in it or disclosed anything inadvertently, but her agility in clarifying an awkward situation was impressive. It was an important lesson for me in understanding the sequencing of who knows what and when. It’s not a matter of withholding information inappropriately, but there is an impressive effort behind choreographing communication and navigating care which you have only one chance to get right. I shifted my weight, easing my right foot from the tackiness of the tufted acrylic and trying discreetly to find a less adhesive patch: I failed.
Dawn moaned about her forthcoming visits to the hospital. She would be there three times next week for her uncontrolled diabetes, her new teeth and now Dad. Although she didn’t work, it was clearly going to be inconvenient, time consuming and expensive. And I had to remind myself that some of her resentment might be rooted in the knowledge that she had been through all this before and not that long ago.
Liz rummaged through the carrier bag which was Mr Hawkins’ pharmacy. It wasn’t full, but it was weighed down with the accumulation of tablets collected over time. Her prescriber’s eye noticed there was an adequate supply of decent pain killers, the biggest priority in her view, but that the rest needed reviewing by the GP. She made a note. Prescribing, she told me later, was one of the most liberating innovations in her district nursing career. It saved so much time and hassle for both her and her patients. And she was clear that the message about microbial resistance to antibiotics had hit home. She was very reluctant to prescribe antibiotics whereas she would happily prescribe the most powerful pain killers when they were needed.
“We’re almost there” Liz announced heralding the end of the assessment. It just remained for her to do a check of Mr Hawkins’ skin and to weigh him. We had already seen most of his skin albeit inadvertently, but Liz got his permission to check his back and buttocks. As I pondered the absolute necessity to do this her diligence proved her right. There was a small abrasion on his left shoulder: an unexpected, small and important find. Mr Hawkins thought there was some sort of irritation there but had not known what it was or what had caused it. Liz noted it and dressed it to protect it. Dawn fetched the bathroom scales. Liz stood up and moved her bag out of the way to create space for Dawn to plonk them down. Mr Hawkins thought he normally weighed about 10 stone. He was now 6. And then there was a knock at the door. Having seen her car arrive Dawn said “That’s your sister. Good job I got her card done. Get your trousers on”.
It turned out to be a timely interruption because it threw up a range of previously undisclosed arrangements about where Mr Hawkins should live and who should look after him. His sister said he couldn’t go back to his own flat and it was clear Dawn could not cope with looking after him, so she had started discussions with social services to rehouse him. My heart sunk. Just looking at him led me to believe he didn’t have time to be rehoused and that a care home with nursing would be the most appropriate option. But now Liz and I were on the doorstep being ushered out, it was an awkward moment to have such a difficult conversation. Undaunted, Liz tackled it head on with real sensitivity. It didn’t take long to realise Dawn’s aunt wasn’t in denial but really hadn’t understood how close her brother was to the end of his life and that rehousing was a very good and sympathetic idea, but not in these circumstances. Relying on her vast experience Liz was able confidently to suggest more appropriate options and to help negotiate the system with social services and everyone else who needed to be involved. Mr Hawkins’ sister immediately relaxed into understanding Liz’s faultless reasoning and Dawn, just for a fleeting moment, looked relieved.
I was drained, but to put it into perspective, the last hour standing on a sticky carpet was the easy bit. Liz did the hard work. She was awesome in her dexterous conversations, juggling difficult social circumstances along with the relationship between three family members whilst also doing a thorough and expert nursing assessment. All in a day’s work. Complexity made to look as easy as this is so skilful. But that was not all, we dodged the rain, got back into the car and went off to see Brian.
It was a warm summer shower, so it was a bit surprising to be let into Brian’s open plan sitting-dining room and kitchen to searing, artificial heat. The atmosphere was, to say the least, fusty. Brian was large, scruffy and charming. Looking beyond the stained clothing his two bulges were obvious. His rotund, bare abdomen was ready to receive the Clexane Liz was there to give. And the bulge in his neck was the reason he needed an anticoagulant injection. He was recovering from chemotherapy for this tumour and was due, in a couple of days, to start radiotherapy. But his overriding problem was his dry throat and husky voice. He explored what could be done about his voice with Liz. The benefits of honey and lemon drinks and throat lozenges were debated. I thought turning the heat down might actually help, but the sad reality was that there was a more fundamental cause of his problem unrelated to the dry atmosphere.
Brian’s priority, important though it was to him, was not shared by Liz. She started writing up her notes which she constructed as the opportunity to talk to Brian about the next phase of treatment for his tumour. “Tumour, what tumour? You mean the lump in my neck is a tumour?” challenged Brian. Another heart sinking moment. He had already spoken about chemotherapy, he knew he was about the have radiotherapy to his neck, but hadn’t computed the connection between this radical treatment and a tumour. Liz embarked on the treacherous territory of a straightforward explanation as I tried to look invisible. She was slightly thrown by this change of direction, but she talked sensitively and knowledgeably about Brian’s treatments and his “growth”. I wondered if using new terminology would be even more confusing, but evidently not. Brian gave every indication he understood that his growth needed two types of aggressive treatments to kill the rapidly growing cells in his neck. She didn’t mention cancer, which, as a mere observer I thought was appropriate, but she did suggest to Brian some questions he might ask of his specialist when he next visited hospital for his radiotherapy consultation. For a visit which was just to give a quick subcutaneous jab, a lot of difficult territory was covered smoothly and skilfully. As we left, Brian seemed delighted to have had Liz’s views about the benefits and effects of radiotherapy, but was most keen to let her know next time she visited how the honey and lemon worked out.
Back in the car, I think it’s fair to say both our spirits slumped. Had we left Brian better informed? Was he in denial about his condition? His obsession with a tincture to soothe his sore throat and husky voice made me wonder. Liz and I discussed the outcome of this visit and, despite her reservations about what she could have done differently, I admired her ability to reflect openly and, in all honesty, I have no idea how she could have handled such a convoluted and challenging conversation any more effectively than she did. After all, it was Brian’s call, his needs were paramount, not ours.
On our way to the final visit Liz explained the circumstances of the sisters we were about to see. Clearly nothing on her caseload was straightforward and the sisters were no exception. Ostensibly, this was a visit to do a leg ulcer dressing with compression bandaging on a woman in her eighties. She had recently had a fractured neck of femur pinned which had impaired her mobility, so her sister had moved in to look after her. Mabel and Flo live in a purpose built block in flats opposite one another. We approached the front door of the building and Liz murmured under her breath, “I hope the bell works”. She pressed the bell marked “trade”. It didn’t respond. “Bother” was the polite reaction. That meant we had to ring the doorbell of the flat to summon Flo to negotiate, not only Mabel’s hefty and willful front door, but also the half-dozen concrete steps down into the porch. The reason for Liz’s concern became apparent as Flo gingerly emerged from the shadows hanging on to the handrail and feeling her way in tartan slippers with pom-poms on the toes. She wore a sleeveless floral dress which showed she was bothered about her appearance despite being 94 and blind. The porch door inched open tentatively, “hello, it’s the nurse, it’s Liz” said Liz. The paradox of Flo’s complete vulnerability and her determined independence struck me at one and the same time. We could have been anyone with a range of motives, but at the sound of Liz’s voice Flo broke into a beaming smile. Liz introduced me and Flo’s bright blue eyes gave me a touching but unseeing welcome.
In the sitting room Mabel was also warm and welcoming, and I sensed, a little relieved to see her sister safely return: she seemed to harbour an anxiety that since her accident Flo could be next and what would that mean for the pair of them?
Since her fall Mabel had slept on a single bed in her sitting room “to make things easier”. I’m not sure how really, but because the bedroom was full, absolutely full, of cardboard boxes it seemed a reasonable option and it was not my place to question it. Flo had decamped from her flat and also slept in the sitting room. Her makeshift bed was two wooden framed armchairs tied together. She claimed it was comfortable and the arms of the chairs stopped her rolling out. There was not much space left in the room but I was intrigued to see that in front of a rather elderly television was a row of eight spectacle cases: six of them were anonymous but two were labelled “reading” and “tv”. I wondered which pair Mabel was actually wearing. In the meantime Liz was on her knees and down to business undressing Mabel’s ulcerated leg. Flo and I were casual bystanders and while Liz was deftly plying her trade Flo took an interest in who I was and what I was doing. Our chatting was interrupted by Liz suggesting that it was time to wash Mabel’s leg – a weekly treat every time the bandages were changed and essential in maintaining the integrity of the skin. She asked if she could get a bowl of water, but Flo insisted she would fetch it. She felt her way out to the bathroom and moments later reappeared with a bowl between her hands and a towel draped over her right arm. Her elbows were jutting out to create her natural sat nav and she completed the journey to the sitting room faultlessly.
Mabel was grateful for the refreshing wash as Liz patted her leg dry and started to reapply the obviously therapeutic bandages in their intriguing layers and patterns. Liz is clearly adept at compression bandaging, but it wasn’t always so. She remembers that when she started district nursing it hadn’t been introduced and leg ulcer care was very hit and miss. Once she had learnt the technique she tried it on a patient who had had a leg ulcer since the Second World War. After nearly 50 years of suffering that leg ulcer was healed in two years – slow progress, but progress all the same and well worth it. No wonder Liz has an enduring passion for the effectiveness of compression bandaging. It’s one of the most important developments in care (along with syringe drivers and prescribing) that she has experienced as a district nurse. And one which has had the most impact on the way she works and the outcomes for patients.
As Liz was finishing the bandaging, Mabel said that Craig had done the bandaging last week. He had made a very good job of it and, as a third year student nurse, was clearly developing excellent skills during his placement. We happened to meet him later and could give him this positive feedback which was promptly recorded in his portfolio as evidence of his achievements. This was the second placement he had undertaken with the community nursing team. He’d chosen to use his elective placement in this way to help him confirm that this would be his preferred field of practice when he qualifies. It was brilliant to see a student so enthused about district nursing and to have had the best experience to make it an obvious career choice.
In the meantime, Liz was tidying up and Flo was clearing away the bowl and towel – a task I wasn’t allowed to perform for her! Flo was out of the room and Liz embarked on one of her fearlessly difficult conversations with Mabel. Liz had told me earlier that she had broached the subject of moving with Mabel, but that Flo was doggedly resistant. She had in mind purpose built, warden controlled accommodation at which the sisters could maintain their independence by continuing to have separate flats but with the confidence there was always someone at hand if they needed anything. “I’m coming round to it” was Mabel’s response when Liz asked if she’d thought any more about the suggestion. Liz’s eyes sparkled with enthusiasm at this significant step forward. It’s no mean feat trying to rehouse someone, let alone two people who need to be near each other but not living together. The bureaucratic wheels grind very slowly even when everyone involved is heading in the same direction, but Flo’s views were so far holding the plans back. Flo came back into the room and instantly knew what the quiet and by now cryptic conversation was about. There’s no fooling her so Mabel asked her the direct question. Would she consider moving? “I’ll think about it” she said with all the fervour of a diplomat trying to find yet another way of saying “No”. Liz knew there was no point pushing any further. The time would come and it had to be the right time. I only hoped there was time to make the decision at their own speed and on their own terms before they became any more vulnerable and the decision was effectively made for them. My head was buzzing with the possibilities of what might happen next to these two devoted and charming sisters, but whatever it was, it clearly had to be their decision. The masterful influence of Liz’s suggestions could only be left like seeds to germinate.
Back in the car we debriefed and had our first slug of water since we left the office. Liz turned to her infallible patient recording system (her diary and pen) and made notes of things to follow up as a consequence of this morning’s events. Rehousing the sisters was clearly playing on her mind and from her notes I could see she was keen to not let the initiative drop but was also purposefully pondering about what to do next – and what to do next for the best. There was a fine balance between pushing at a stiff and only partly open door to make the referrals for rehousing and injecting too much speed into the process which could alienate the sisters and undermine the trust and confidence they obviously placed in Liz to advocate for them jointly.
Reflecting on the morning’s experience led me to realise that having someone as skilled, knowledgeable and experienced as Liz leading a district nursing team was invaluable. She has the expertise and qualifications of a specialist but is also practising as an advanced generalist: she can tackle anything that confronts her with agility and serenity. She has years of experience and an encyclopaedic memory for front doors, but I am left in awe at what goes on behind those front doors. They are where consummate professionals like Liz have to leave their personal prejudices and judgements and become the practitioners and advocates their patients need of them. No mean feat. It’s a role that’s full of challenges, but one that is fulfilled to a high degree of excellence, day in day out, by thousands of district nurses hidden behind closed doors.
Deputy Director of Nursing and Midwifery Advisory at the Department of Health
Queen’s Nursing Institute
The Queen's Nurse programme run by the Queen’s Nursing Institute is designed for community nurses who want to develop their professional skills and promote the highest standards of patient care. To find out more visit: http://www.qni.org.uk/
[i] All patients’ and relatives’ names have been changed