Winter is coming (but that’s OK) by @JeffAce3

I might be tempting fate here, but I’m in an unusually bold mood and I’m just going to go for it… it’s time to declare winter 2014/15 officially over.

Despite living here through the last fifteen of them, I’m still a little in awe of Scottish winters with their frozen lochs and snowfalls into April. I grew up in South Wales (which, for those of you who haven’t been there, has a broadly Mediterranean type climate…) and the adjustment to more northerly weather takes a long time. Indeed, the Ospreys rugby team’s narrow miss of the league title this season is largely accredited to our failure to wear thick enough vests during the trips to Edinburgh and Glasgow.

A typical midwinter scene at Torbay, Swansea.

Sadly, it’s hard to mention ‘winter’ in an NHS context without immediately adding ‘pressure’. Locally, this was a record breaking year in terms of winter admissions to hospital and patient activity through primary and community services, a fact which is quite staggering when you think that the previous two winters have also broken records.

 

 

We’ve experienced all the usual difficulties of Norovirus and Flu outbreaks amidst this record activity and it’s to the enormous credit of staff that we’ve maintained extremely high performance levels. For example, the 95% 4 hour wait target in A&E has proved impossible to achieve across much of the UK; our teams not only delivered it, but improved on previous years’ performance. This is much more than an impressive set of statistics; this was a major contribution to good patient experience and safety.

 

 

There are lots of other examples of the huge efforts of staff in improving services throughout the pressures of winter. We’ll be reviewing a range of such information at our NHS Board public meeting in June, so I’d expect forthcoming media reporting to be even more heavily dominated than usual by praise for our teams and their achievements…

We should take pride in these achievements but I’d also like to reflect on how this level and quality of service can be built on as we begin the winter planning for 2015/16. The ‘winter pressure’ this year has fallen squarely on teams of staff dealing with unprecedented gaps in staffing due to well publicised recruitment problems. We have succeeded for our patients this winter frankly because many clinical and support teams have worked harder and longer than ever before. I can make this statement knowing it applies right across our system, from the primary care teams coping with GP vacancies, to the cottage hospital staff managing record levels of occupancy, through to our acute teams juggling rotas around consultant and other doctor vacancies. This is a great reflection on the ethos of our teams, but it can’t surely be the basis of our long term planning; it can’t be our ambition to ask individuals and teams simply to work harder year after year to deal with rising patient activity.

It’s certainly not my ambition and I instead want us to be seen as the outstanding place to work and to develop your career in Scotland. That has to mean relieving some of this pressure on individuals and teams to allow them to focus on continuing to improve our patient experience rather than simply ‘fire-fighting’ a relentlessly rising workload. In years gone by this would have been quite a simple process; a (often young, Welsh) manager would put together some demand and capacity analysis, demonstrate the imbalance and cost out the required extra capacity in a bid to the Health Board. The Board would then consider this in the context of other priorities and, more often than not, commit a proportion of its growth monies to fix the problem. Life’s now a lot more complicated. In the next few years this ‘growth’ funding barely keeps pace with health inflation and even where money is available, we’ve no longer a guarantee that we can recruit to traditional roles.

But whilst previous solutions may no longer be as effective, I think we can still allow in some cautious springtime optimism that a more sustainable future is achievable.

Health and Adult Social Care integration is one of the reasons to believe the future could look significantly different. First the injection of pragmatism; integration doesn’t magic up one more GP, social worker or care worker, doesn’t add a pound to our stretched budgets or endow our managers with (even) greater wisdom. It does, however, give us the first real opportunity to pool our resources and expertise in each of the region’s natural localities and try to create local models of health and care that are more effective at managing complex conditions in home or community settings. We now have a bank of evidence from the Putting You First change programme of the impact of small scale redesigns, integration allows us to take the best of these and implement them at a scale that could make a fundamental difference to flows of patients and to the quality of experience of those patients. This will be a difficult process of enormous change to many clinical practices and pathways, but it seems to me that it offers promise of genuine sustainability of service quality as an alternative to a future of perpetual winter pressures. Our integration scheme is the most ambitious in Scotland, has been approved by both Board and Council and we go live on 1 April 2016 after a period of ‘shadow’ running this year.

Similarly, the ‘Change Programme’ (part of the suite of work around the new acute build) gives us a once in a generation chance to examine every aspect of our organisation of acute workload. We know that come 2017/18 we’ll have the finest DGH facility in Europe, the contract’s signed and the diggers are on site. We need now to ensure that services in the hospital from acute receiving to theatres to outpatient reviews are reorganised in a way that gives staff the very best opportunity to deliver high quality care and act as the best advert for recruitment of top class staff. This isn’t quick fix work, but again offers us an opportunity for improvement that we’d be foolish to miss.

I don’t want to put a rose tinted perspective on what are the most challenging times in health services I’ve seen in my career. I also appreciate that engaging in such major redesign programmes is particularly difficult when faced with increased demands of the day (and night) job. But I do think these programmes are our best strategy, and that locally we have a unique opportunity to create a future that feels a bit more balanced, and winters that feel a little more fun.

Jeff Ace is Chief Executive Officer for NHS Dumfries and Galloway

 

Kathleen’s Journey

How many of you have lost a loved one to cancer? How many of you have heard the term “he or she died peacefully”? Anyone who has witnessed a loved one dying in this way will appreciate that there is often nothing peaceful about it. It is heartbreaking, you are in fearful limbo, undergoing constant challenges and the result is painful and exhausting both physically and mentally. This may sound a little dramatic but it is an honest assessment and it was honesty which I felt was lacking in the story I wish to tell you.

At the beginning of 2014 Kathleen, my Mum, had a follow up Colonoscopy having previously had polyps. However on the day the procedure was performed there were complications and the test was abandoned. She was informed she would be recalled but sadly had not yet received this appointment at the beginning of 2015, when she died.

She became unwell during the summer of 2014; fatigue, loss of appetite and change in bowel habit. As her symptoms worsened she isolated herself socially. Her GP prescribed laxatives but they just made things worse and caused abdominal pain. I would say at this point she had no quality of life. She visited her GP and asked for more investigations but was informed that tests such as CT scans were expensive and she did not require one. This shocked us.

In November her abdomen became distended and the pain became worse. We were left with no option other than to take her to the Emergency Department. To my horror Mum was sent home with more laxatives but was so poorly had to return the next day. Once again they wished to discharge her but my dad stuck to his guns and insisted on admission. She had a number of tests and on the following Tuesday a CT of her abdomen. This revealed bowel and ovarian cancer. 

When Dad was asked by the Consultant to be present when he gave Mum the results he knew it was going to be bad. The Consultant informed them that the cancer had spread and that Mum only had weeks to live. There was no treatment to offer. There is no skirting around news like that. It was devastating but we were grateful that it was delivered with humanity, compassion and honesty. You don’t forget these things. As a family were reeling. The grandchildren were heartbroken and we all struggled to come to terms with the news. And then…..

A few days later another doctor came and told us the CT results were ‘inconclusive’. This news was delivered with a flippancy and obvious lack of understanding to how we all felt. We were then told that it would be over a week until we knew what the plan was as we needed to wait for a multidisciplinary meeting. This was almost too much but we clung to the hope now presented to us. Maybe….

Then we were told that there was no curative treatment but there was an option of palliative chemotherapy which MAY shrink the tumours. They offered 6 months of chemo which sounded hopeful and Mum went up to Edinburgh. However after the first course she suffered a perforated bowel, apparently as a result of the chemo, and was admitted to the palliative care unit. She was now asked what she wanted and discussion turned to the funeral!

Why was my Mothers final 6 months such a roller coaster? Why did it take so long to diagnose her? The end result would most likely have been the same but did she have to go through so much pain and confusion? I understand that an administrative error led to Mum not getting her follow up colonoscopy. This is inexcusable but when she became truly ill no-one seemed to listen to her. Listen to her symptoms, listen to her story. Had an individual healthcare professional actually listened to Mum or Dad and taken them seriously then I have no doubt she would have at least had her scan and diagnosis earlier.

And then all the confusion about “was it cancer or was it not?” It clearly was and the first Consultant we saw was clear about this and, not only did he honestly tell us the news and prognosis, he was right: she only had a few weeks left. A few weeks that could have been much kinder had she not been given false hope and a worthless (and uncomfortable) trip to Edinburgh. It was only when she got to the palliative care unit that they asked….What matters to You?

That is all it required….someone to listen and honesty.

Mum died in the palliative care unit well cared for and in dignity. The staff were honest and kind. They listened to her needs and provided them. We are very grateful to them and their professionalism.

This week’s blogger wishes to remain anonymous

Having a bad day? by @kendonaldson

Are you having a bad day? Or has the day just begun and you are struggling to face it – you know the ward is full but you have 8 admissions and no one knows where to put them. Perhaps you have 6 meetings lined up and you know that all will be challenging with little achieved. Or maybe you have a ward round then a clinic and you already have 50 unopened emails and no prospect of time to deal with them except when you get home later tonight. And on top of this your Dad is sick, or maybe your partner has just lost their job or your child is struggling in school. Sound familiar?

Very few of us come to work with absolutely no worries and even less of us find our days work problem free. We all react and behave differently to these stressors. Some thrive on them and perform even better than expected. Others struggle and this often becomes apparent from day to day. I know I struggle and often I don’t quite realise it but I do have a few ‘barometers’ that tell me things are getting bad. People say things like:

“You’re sighing a lot Ken”

“I heard you sighing from the end of the corridor”

“You’ve just arrived and you are sighing already!” (Sighing features quite a lot)

I saw you walking down the corridor and your head was low and your face was miserable. What’s up?”

“Ken, you were a bit short with them.”

And, probably most telling of all…

“Daddy, why are you so grumpy?” Sadly, sometimes said through tears.

Its when I hear phrases like these that I realise its time to take stock and focus on what really matters to me: my family, my friends and doing the job well, not rushing things and upsetting people.

I recently read a bit of advice from a psychologist. She holds a glass of water and asks her students how heavy it is. There is a range of answers but the point isn’t the absolute weight, its the fact that as she holds it longer and longer her arm begins to ache as the glass feels heavier. Ultimately her arm is almost paralysed in pain. Anxiety and stress are a bit like this. The longer you think about something the heavier it becomes until eventually you are paralysed. You need to put the glass down every now and again.

The reality is that working in the NHS is tough. We are short on doctors, nurses, beds and the patients keep on coming. Paperwork changes or the number of forms increase, new IT that seems to hamper rather than help, wards are shut due to norovirus or flu. GP numbers are so low that practices are covering ever increasing areas and more patients. The list goes on but it affects almost all of us.

So why this blog? Well it’s to ask us all to remember that it may not just be you having the bad day. It may be your colleague on the other end of the phone, or the other side of the bed or the other side of the table. They may in fact be having a worse day than you. If we remember this, are kind and considerate to each other and consider that we are actually all on the same team then it might make our day a little better. Random acts of kindness, however small, can make a difference: saying thank you, making a cup of tea, a smile.

At the end of the day it’s not just you or your colleagues who lose out. It’s also the patient and, chances are, they are having a significantly harder day than you!

Ken Donaldson is a Consultant Nephrologist and Associate Medical Director at NHS Dumfries and Galooway.

Flexible Visiting – Who is really the visitor? by @KeriVannuil

As a staff nurse in ward 12 acute stroke/ respiratory, my day is governed by time- medication rounds, breakfast time, personal care, observations etc the list can be endless. There is one time of the day that can strike fear into the hearts of many medical professionals and that is VISITING time!

Why is it seen as such an inconvenience on our day?

Why do we feel we don’t have sufficient time to spend with the patients and their loved ones giving accurate information about their current treatment plan?

And why do we feel we won’t be able to get on with the other tasks requiring our attention if the visitors are present?

Last year a member of my family was admitted to DGRI and this is when I became a visitor for the first time. At the time the trust was operating an open visiting policy from 2pm to 8pm. As a nurse I thought that was ample time for anyone to fit a visit in to their loved one. However I soon discovered that if I was on a late shift from 1.30pm until 9.30pm I was not going to be able to spend as time with my relative as I would like.

How do people on shifts fit everything in? Surely there is a friendlier approach to visiting?

Following the recent person centred care collaborative I have been thinking a lot about DGRI’s previous trial of “open visiting”. Having listened to experiences of other colleagues within NHS Scotland I was embarrassed to say we do not have open visiting.

During a trial of open visiting the wards were open from 11am which meant we did not have an influx of visitors at 2pm which was usually our busiest time. The early visiting also meant we could catch up with relatives and discuss care plans and discharge planning.   Since having our new open visiting times we have unfortunately gone back to the influx at 2pm.

As a ward we are very good with palliative/ dementia patients at saying visitors can come any time if it’s what they want or need. But this surely must happen for every patient every time by every nurse to be truly person centred?

In our area we did a 3 month pilot of flexible visiting. The aim of the pilot was to allow patients to have their visitors come in at a time of their choosing and allowed the visitors to come at a time which fitted in with them, even to just say a quick “Hello” before or after work. 

Goal-All patients should be able to see their loved ones/ visitors at any time of their choosing.

The aim of this trial is to assess the impact of unrestricted visiting on the following areas of patient experience

                                   – Patient Centred Care

                                   – Reduction in complaints

                                   – Patient experience

                                   – Staff experience.

                                   – enhanced access to MDT

                                  – enhances professional behaviours.

                                   – Creates a transparent working environment

 

 

I know that many people will have their reservations about this trial but I would hope those people would put themselves in that patient or family member’s position. As members of a profession that work shifts we should also be able to understand the need for flexibility for each patient and their loved ones.

Getting the information right for patients and staff is crucial to the success of this trial and if the information uses a common sense approach I would hope this will give staff the confidence to get on board, take ownership and make this a success for everyone involved.

As a nursing team we decided to begin the trial on the 1^st of November 2014 until the 5^th of January 2015.

The most challenging aspect of the flexible visiting was actually the amount of time it took explaining it to the patients and visitors. As this was a small scale trail the only information available was the posters and booklets produced by our team.

 

The flexible visiting was very well received by patients, visitors and staff.

Staff commented that it reduced the influx of visitors at 2 pm and meant the staff could then spend more time updating relatives and answering any questions they had throughout the day.

During the trial there was no incidence of confrontation when relatives were asked to step out while personal care was carried out or when privacy was required by the doctors.

After the trail a discussion was held with staff regarding their experience and also patients and relatives. It was felt flexible visiting did not have any detrimental effect on the daily running of the ward and it enhanced patient and relative experience. It also reduced the workload at peak times on nurses as they were able to speak to visitors throughout the day

As a team we made the decision to make flexible visiting standard practice within ward 12. I would encourage all wards to approach this with an open mind and give it a try. With the new build in a few years it will be even more important to be flexible with visiting.

As a medical team we are just with the patient a relatively short time so I guess it’s really us that are visiting.

 

Keri Van-Nuil is a Staff Nurse on Ward 12 and a Capacity Manager at Dumfries and Galloway Royal Infirmary

Team work – Ward 12 style by @jacalinanicnac

I have been nursing for 33 years this November and over those years I have experienced a variety of good and not so good team working. Those experiences have influenced me greatly to form the nurse and team leader I am today.

My job as Senior Charge Nurse in Ward 12 is to provide a high standard of effective care in an environment that patients feel safe in and by a team that feel confident and supported to do so , and everything else that falls within the patient / relative experience. Working in a team can be challenging but also fulfilling when the job is done well. We couldn’t do what we do every day without good team work .

WHAT IS A TEAM?

A group of people that share a common purpose, are committed and empowered to set goals and problem solve. Without these traits they are not a team but a group of people who work together, a work group.

A patient sent us this thank-you card ,

“Together Everyone Achieves More”

Together = we have a common purpose = giving excellent care.

Everyone = all who work in Ward 12= everyone has a voice.

Achieves = how we deliver our care = evidence based, safe and effective.

My role as team leader is to make clear the team goals, identify the issues that stop the team from achieving their goals and solve those issues with the help of the team .We would do this by doing tests of change , getting feedback and auditing improvement . My job is to create an environment where team members are supported and valued in the work place .By keeping the team motivated, developing and maintaining skills, being aware of individual strengths and weaknesses and attitudes and behaviours I can enhance the staff experience. I was encouraged and guided by work done by Julie Booth, Senior Charge Nurse in Ward 3. Julie and her team developed Values and Standards for the ward. All our staff had input in developing the ward standards and all staff agree to work by them. The basis for the Values and Standards is respect, being non judgemental, and being respectfully open and honest in giving and receiving feedback.

As well as the patient wellbeing, the wellbeing of my staff has equal standing. I believe you can’t enhance or improve the patients experience unless you value and enhance your staff experience. I have encouraged staff to attend the National Person Centred Health and Care Programme, and our local Patient experience events. The staff come back to the ward enthused with ideas for change, they share them with colleagues and then as a team we plan how best to introduce those changes to the benefit of patients and staff.

One such idea was after a local Patient Experience event. Team members returned to the ward and wanted to introduce reflection for staff. The team felt that after a busy shift there was no opportunity for them to say how that shift was for them. Staff felt they took their thoughts home and returned on their next shift with heavy minds and frustrations from the previous shift.

We have a definition of reflection, an aim and a process for reflection. The purpose of the reflection session was to be able to speak freely about their experience of that shift , any challenges and to discuss what could have worked better, or to say what was good about that shift and how that could be embedded. It is time limited to 10 minutes at a convenient time, it involves all nurses on the shift, there is a lead person for the session (not necessarily the Senior Charge Nurse, or person in charge), and ground rules were established = confidential- no notes taken – what was said in the room stayed in the room, discussions are relaxed and non confrontational, open and honest. Any “bigger” issues arising would be discussed with the staff member and myself out with the reflection session. The sessions were greeted with apprehension by some staff who found it difficult to speak about their experiences, but after a few sessions everyone soon got into the swing of it. These sessions were soon generating ideas for improvement and themes of frustrations in the work place. We added 2 boxes , one where staff could write down their good ideas =Golden Nuggets box, and one where they could write what was annoying on their shift = The Bug box.( replacing what you had used and tidying up were the top 2 ). We then discuss what is in the boxes each week and plan how to improve or change our practice. We have a questionnaire for staff for feedback and we use the safety cross check chart per month to record our consistency. We saw very quickly that staff felt they had the chance to reflect on the challenges and the successes of their shift and by giving everyone the chance to talk about it freely the staff felt they no longer left work feeling burdened by “work stuff”. This has improved our communication within the team and improved staff morale .It takes commitment by all staff to maintain these sessions, when we are extremely busy some sessions do not happen and the staff comment that they miss them. It is my job to raise the focus again and encourage the staff to keep it going.

Dale Stewart and Wendy Langan who facilitated the reflection development.

Another idea introduced by the Health Care Support Workers in the ward was to have a welcome and information leaflet for all staff coming to help in the ward. It starts with thank you for coming to help in the ward today, you will be working with….. , the ward routine is…. , your break is… . We have feedback sheets which we review monthly and encourage suggestions to improve staff’s short term experience whilst in ward12. We have had a lot of positive feedback from staff helping in the ward and they look forward to coming again.

By encouraging staff to develop their ideas and improve the team performance they take ownership of change and enthuse others to do the same. This makes my job easier it enhances the patient care and journey which we measure with our patient questionnaires; What did we do well? What could we have done better?

Being part of a good team gives you a sense of pride in achievement and celebrating success, and camaraderie in supporting the team. In Ward 12 a wicked sense of humour and a liking for sarcasm will also enhance your experience!

 

Celebrating success , Susan ,Drew and Mary.

I would like to dedicate this blog to Charge Nurse Heather Renwick who retires this week after an outstanding 37 year nursing career, one of my excellent experiences in my nursing career.

Jackie Nicholson is the Senior Charge Nurse on Ward 12 at Dumfries and Galloway Royal Infirmary