Let’s Get Physical by Amanda Taka

With the festive season looming towards us, the last thing you want to be told is to get physical right? However with 8 weeks to Christmas, we still have plenty of time before we carve the turkey. The Physical Activity Guidelines for adults recommend that we build up to 30 minutes of moderate intensity activity 5 days out of 7. But how do we fit this in to our busy working lives? And is it worth the effort?

We’ve all heard of the benefits of exercising, but here’s a recap:

Regular exercise:

• reduces the risk of many diseases such as type 2 diabetes, coronary heart disease and stroke
• helps us to maintain a healthy weight
• improves our self esteem
• promotes a sense of wellbeing
• reduces symptoms of depression and anxiety

Working in the NHS we can’t fail to be reminded of what we should be doing and why. However, being ready, willing and able to make those lifestyle changes can be another matter.

And before you write me off as one of those typical fitness fanatics, let me tell you a bit of my story. At school I was always the last to be picked for team games, I didn’t learn to swim until I was 16 because I was frightened to put my head under water, I hated PE and used to hide in the Geography block toilets to avoid detection. My Mum and Dad told me to stay as I was because playing squash and golf gave you a heart attack. My Dad’s motto was ‘built for comfort not for speed’. They were both overweight and although I wasn’t, I always knew I would be too because that’s what happened to us in our family. And so it would have gone on if I hadn’t returned to Uni and trained to be a nurse.

Anyone who has trained to be a nurse knows that it changes you. It changes the way you look at people, the way to speak to people and the way you react to people. Furthermore, it challenges hard held beliefs and preconceptions. Studying at UWS under the influence of Julie Orr and her colleagues, I began to see that getting older doesn’t need to mean that we inevitably get bigger and slower. I realised that the ability to change was within me and additionally I had the power to influence my young daughters’ long term health.

This Eureka moment happened to me in the middle of one lecture towards the end of my training. Julie was telling us about when she was doing her Masters and how she fitted it into family life “and I still went to the gym three times a week” was the phrase that hit home for me. Like a bolt of lightning I realised that I needed to make physical activity a priority for me. I started to take up yoga again – something that I hadn’t done regularly since I’d had my children. Slowly I began to build physical activity into my day, feeling very smug about it too thank-you very much.

After qualifying, I got a job on a fast paced 22 bedded respiratory ward. Working full time was enough to achieve my 30 minutes a day. Life doesn’t stay static though, and I moved to a 6 bedded Coronary Care Unit. My daily steps dropped, my waistband started to feel a bit tighter and I put half a stone on. I realised that I had to change tactics. I began to walk into town on my days off, I got myself a Fitbit and tried to do 10,000 steps a day, challenging nurses on other wards inspired my competitive streak. Obviously when you put physical activity first, other things slide. I won’t be winning any Good Housekeeping awards imminently and I don’t have time to watch TV. But as I see it, the benefits outweigh the costs.

Then earlier this year I left Coronary Care and moved to the Keep Well project here in Dumfries and Galloway. Keep Well is an anticipatory person-centred service that aims to reduce health inequalities. Part of this role involves delivering brief interventions for physical activity. I started to see that the guidelines weren’t going to be achievable for everyone – like the 64 year old lady who had to use a wheelchair because of her COPD. In that case, the message is do what you can, keep doing it and try and build on what you can do. Most of my clients with long term conditions are very aware of their limitations and they know better than I do, what is achievable for them.

Changing from a shift based work life to a ‘normal’ 8.30 to 4.30 job required further readjustment to my physical activity routine. Covering the whole of D&G has found me spending large amounts of time in the car. But the advantage is that I now have my weekends free and I make sure I do something active with my children. But I was struggling to do something on week days. So I started a 90 day Yoga challenge – 30 minutes of aerobic yoga for 90 days. The only time of the day I could fit this in was before everyone else got up. I found that I was so used to getting up at 5am to go to Carlisle that doing yoga at 6.30am was achievable for me. In all honesty, I haven’t made it onto my yoga mat every single day because sometimes life gets in the way, but I didn’t beat myself up because I knew that tomorrow was another day.

Now I realise that getting up at 6am to exercise isn’t going to work for everyone. So, I suppose the main message I’m trying to share is

• Find an activity that you enjoy
• Small changes really make the difference if you do them often enough
• Give yourself permission to exercise – no one else can do it for you
• Don’t give up if you miss a few days/weeks/months. Life gets busy and big events sometimes engulf us.
• Set a SMART goal, running the London marathon next April is not appropriate for everyone. Parking the car as far away from the office 3 days a week could be more achievable.

As the largest occupational group in Scotland, we nurses are in an incredible position to reach a huge number of people. If we start with ourselves, this will ripple out to our families, our communities and ultimately to the Scottish population.

Lesley Fightmaster Yoga Fix 90 – 90 day to build a healthy habit https://www.youtube.com/watch?v=ArZDT5zXSR0

Amanda Taka is a Keep Well Nurse based in Public Health, Crichton Royal Hospital and a Coronary Care Nurse with North Cumbria University Hospitals NHS Trust.

All Good Things Come in 3’s (or 4’s or more?) by Phil Myers

What would Stanley make of it?

Hidden eKIS by @kendonaldson

I took a phone call from a patient’s son some months ago. His Dad, Edward, had recently spent 24 hours in our hospital and whilst all members of staff had been kind and helpful he had a few issues he wished to discuss with me. Edward is 83. He had a heart attack 3 weeks ago and has ongoing chest pains. He has Stage 4 Chronic Kidney Disease (about 20% function) and leukaemia. Sadly this last is not amenable to any treatment.

In short Edward has multiple long term conditions and is dying from his leukaemia. He still has a reasonable quality of life and, with his family, has discussed clearly what his wishes for the future are. His GP has entered all of this into his eKIS or Electronic Key Information Summary which can be accessed by all healthcare professionals though the ECS, Electronic care Summary.

So when Edward got sudden onset severe chest pain last week the sequence of events was a surprise to him and his family. Paramedics were called and when they arrived they did an ECG. They then proceeded to fax this to the Golden Jubilee Hospital in Glasgow and discuss his case with the team there. All the time they did this Edward’s son was quietly explaining that this was not necessary, his Dad did not want this level of intervention and that this detail was all available on eKIS. The paramedics had not heard of, and were unsure how to access, eKIS. They apologised for this and took Edward to Dumfries. At least he did not have to go to Glasgow!

On arrival on the Emergency Department the same thing happened. Nobody knew what eKIS was and how to access it. I’m afraid this was replicated in the medical assessment unit. The following day, after Edward had been assessed, he was deemed fit for discharge – a blood transfusion had sorted his anaemia and angina. The first the family knew was when Edward phoned them to tell them. “And” he added “I can now drive!” He was delighted as driving is very important to him.

When Edward’s son arrived, a little surprised and anxious, he discovered that the team, who still had not accessed the eKIS, did not know that Edward had had a heart attack 3 weeks prior and hence couldn’t drive, had not contacted the palliative care team (outlined in eKIS on any admission) and had not really thought through his discharge. “Its not very Holistic” was his understated comment to me. It all got sorted and Edward got home (although a little aggrieved that he couldn’t in fact drive) and neither he nor his family wish to complain but they want to understand why eKIS seems to be a mystery to the Scottish Ambulance Service and most of secondary care.

So what is eKIS? If you click here you will get access to a useful ‘FAQs” about eKIS. You can also read Neil Kellys blog “The KIS of Life”, published on the 14th of February 2014, here. Very simply eKIS is an electronic handover. GPs, in consultation with patients and their families, can enter details about DNACPR, treatment escalation and goals and priorities for the future. The idea is to prevent things like unnecessary trips to Glasgow or, if arriving at the ED in a collapsed state, CTs or endoscopies or trips to theatre. Basically it’s an attempt to communicate a patients wishes to all who care for them. Not much use though if no-one looks at it.

Its important for us all to be aware of eKIS. Not just those of us at the front door. If I review a patient in a clinic or on a ward round and we discuss issues about the future and decisions are made then I should communicate this to the GP and ask for it to be included on their eKIS. I confess I am not very good at this but hope that this story will significantly improve my communication efforts. I must also confess that I did not have a password for ECS when I heard this story but I have remedied that.

It’s almost a daily mantra in my life – “it’s all about communication”. So many small (and not so small!) things go wrong because of poor communication. eKIS is an excellent tool aimed at reducing communication errors. Let’s not be like Peter Pan and keep it hidden, let’s use it.

Postscript: Sadly, since writing this blog, Edward has died. He had a number of admissions to hospital following the one outlined above and had similar problems with communication however died peacefully in the Alexandra Unit.

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

Decisions Decisions by David Macnair

Do you make decisions at work? I’ve asked this question a lot. The reply is usually the same. A hesitant nod of the head, perhaps. Or a lop-sided shrug with that expression that says “Dunno. Do I?” Despite making decisions every minute of every day, we most often don’t notice we are doing it. Which means we can make it better. We can ask, “Do you make good decisions?”

In fact, we human beings are decision making machines. We might make life or death decisions about patient care. But it is mostly humdrum day to day decisions. When am I going to get up for work? Which buzzer am I going to answer first? Shall I go for a pee before I do the next task? Should I push or pull that door?

First let us look at how we make decisions. These four categories cover most of the ways we make decisions in a clinical setting. They are:

• Option appraisal
• Rule based
• Novel solution
• Recognition primed

Let’s take a look at each of these in some more detail.

1: an example of a poor decision

Option Appraisal

Do you recognise this heroic looking guy?

2: The Thinker

Option appraisal is the classical approach to decision making. One sits hunched with chin in hand and thinks of all of the possible options for a given situation. Each of these options is weighed up individually, looking to see the pros and cons. When finally a single best option is clear, a decision is taken. The major benefit of this approach is that it is the most likely to produce a good decision for the given situation. It is also easier to justify your decision later. Unfortunately, there are drawbacks. It requires mental effort and time. It requires a systematic approach. If you don’t know all the possible options, you could miss the right one! It requires some background knowledge. A medical example of option appraisal is writing a differential diagnosis. This is a list of possible illnesses (ie options) that a patient with particular symptoms might have. Writing a differential diagnosis forces you to consider diagnoses other than just the one you wrote first.

But is this how we usually make decisions? No! Of course not. If every decision we made required this process, we would become paralysed; unable to get anything done for thinking about it.

Rule based

3: Guidelines say we have to have 5 nurses on the ward. This is Sandra, also known as Claire, Fiona, Jade and Emma.

This one is easy. Think of a guideline, any guideline. This can be thought of as a “rule” on which to base your decision making. A good example is basic life support. You know the drill (or you should- it’s mandatory!) There are benefits to having a rule. It’s fast. It standardises the decisions. If everyone knows the same guideline, then you can work together as a team. You don’t need to sit down and think- someone else has done the thinking for you.

There are buts. You know there is a guideline for cardiac arrest. What about the one for anaphylaxis? Or escalation of the deteriorating patient? Or the guideline for pre-eclampsia, or diabetes, or needle stick injuries, etcetera etcetera… The trouble is, you need to know there is a rule to follow it. You also need to be able to find that rule. Have you tried looking for a guideline on hippo? It’s not always easy.

Other drawbacks? It doesn’t allow you to think “out of the box”. Guidelines can sometimes be too rigid. Some guidelines are complex, and so easily misunderstood. In these cases, it might be most appropriate to have a copy of the rule to hand as you are carrying out the task. Also you can apply the wrong rule if you have picked up the cues wrong. It wouldn’t be the first time that a patient had been “defibrillated” because an ECG lead was hanging off…

Novel Solutions

While we are on the topic of “thinking out of the box”, we can take a quick look at this one. Novel solutions are things we think up on the fly when there isn’t a solution readily available. An example would be using a tongue depressor to splint a baby’s arm. These solutions are occasionally a necessity, but most likely to result in unintended outcomes.

4: The BBC substitutes sarcasm with inverted commas as the lowest form of wit

Recognition Primed

Which brings us last, but not least, on to recognition primed decision making. It’s that pattern recognition thing. You walk in to a room and immediately just know what’s wrong. This way of thinking was described first when firefighters were being observed. When asked afterwards how they came to a decision, they would say only one option would come to mind, not a whole list like in classical option appraisal. They would then run with that idea, assessing at intervals whether the decision was having the intended effect.

This is how most of us do it. We make a decision from one single best fit option. The major benefit is that it is fast, sometimes supernaturally so. It doesn’t require much mental effort, and so is resistant to stressful situations. However, it is more likely to be wrong than a good sit down and think. In other words, some of your most experienced team members are more likely to be wrong because their pattern recognition has short circuited their decision making process. Be aware of this.

Thinking biases

There are other factors that can affect how we make decisions. Our decision making may be entirely rational, but there are biases that creep in to trick us. Here are some examples:

• Confirmation bias. Take a diagnosis of bleeding for example. We tend to look for the symptoms and signs that confirm our diagnosis. We see the increased heart rate, the decreased blood pressure but ignore the wheezy chest that tells us the diagnosis not bleeding. This is a common failing when humans make decisions. Remedy? Take the symptoms that don’t fit seriously, and do not dismiss them.
• Premature closure. In a similar vein, if we make a diagnosis, we stop looking for another diagnosis. Again this is common, and can often lead to missed problems. Remedy? First, use forcing functions, like writing a list of possibilities rather than just one option. Second, continually review your decisions especially in the light of changes.
• Attribution bias. If something looks like a duck and quacks like a duck, we assume it’s a duck. So if someone looks and acts drunk, we assume he is drunk. Even if his symptoms are caused by a subdural haematoma. Remedy? Look for the facts to either corroborate or contradict your duck theory.
• Base rate neglect. If something looks like a duck and quacks like a duck, don’t assume it’s a Christmas Island Frigatebird. Oddly, sometimes we do ignore the most common things and decide to pick the least likely option. Remedy? Assume it’s a duck. No wait…

5: Not a duck

H.A.L.T .

Our decision making may not be rational. We are human beings and there is most often more than one set of values at play. Decisions are often made when we are Hungry, Angry, Late or Tired. Or indeed is there some other conflict? Do you dislike the person you are making a decision for? Do you disagree with a senior colleague? This happens all the time. A couple of months ago I saw a patient in the emergency room with a head injury. The long and short was that his conscious level was decreased and he needed transferred to Edinburgh. The options were I could take him, or he could go with a nurse transfer. But I’d already been working for 12 hours by this point; the transfer to Edinburgh always takes 5 hours, and it was arguable that he was well enough to go with a nurse rather than an anaesthetist. Ish.

So the decision was made to transfer with a nurse (sorry Sarah). But I second guessed myself and phoned a friend. After discussion, he said “Well, if it was me, I’d go…” So I sloped back to the emergency department to find the patient already out the door! Further decisions were punctuated by interesting vernacular; suffice to say, I ended up in the back of an ambulance after some less than elegant decision making.

What can we learn?

On reflection, there are several things we could learn from this. We need to be aware when we are making decisions. This allows us to think how we are making decisions- is it recognition primed? Is it option appraisal? We can think what aids there are to help us such as rules or guides. We must realise what barriers are in the way of our decision making. Things like hunger, anger, lateness or tiredness can all be dealt with to improve our decision making.

Any last tips? Often it helps to stand back and take time to weigh the options. A colleague can be a valuable resource. If a decision is not clear, talk to someone about it. Possibly most helpful of all, it is important to reflect after the fact. What decision did I make? Did it have the desired effect? Could I improve on it next time?

Do you make good decisions?

David Macnair is a Consultant Anaesthetist at NHS Dumfries and Galloway

 

 

To the World you Might be One Person, but to One Person You Might be the World by @FionaCMcQueen

Over the years, I’ve heard about truly exquisite experiences people have had when they’ve experienced good nursing. Whether it’s been supporting someone to a peaceful death, holding a frightened hand before an operation, or supporting a young person through difficulties, there’s no doubt that good nursing is recognised when you see it. So why don’t we see it all the time? Should we see it all the time? From my perspective- absolutely; excellence in care from every nurse, for every patient, every time. ‘But Fiona, I hear people think, that’s just not possible, you just don’t understand………’

If the profession believes that it’s not possible to deliver excellence in care all of the time, then we will never do it. I’m not saying it’s easy, but I honestly believe it can be done. But we can’t do it alone. When thinking about what gets in the way of that excellence, it could be any one from a long list; not enough staff, staff not appropriately trained, pharmacy not available, doctor not available, equipment not available, staff too busy…….. the list could be endless. But what of the above is impossible to change? What of the above is an acceptable reason for poor care? I would argue none. At times we can be too understanding of the pressures we face when trying to deliver care. It really is a whole system issue, and one that the Scottish Government and NHS Boards are working to improve.

We’ve seen huge leaps and bounds in patient safety with the Scottish Patient Safety Programme, significant increases in the number of nurses employed by Boards when they apply the nursing workforce tools, significant numbers of extra student nurses, and a strategic focus on staff health and wellbeing thorough the national programme, Everyone Matters. So what’s stopping us?

From a national perspective, it’s clear that Boards are under considerable strain; financial pressures are making balancing the budget more essential than ever before. The changing demography is beginning to bite. Whilst the recession has perhaps delayed some of the workforce challenges that we are bound to meet with the reduction in working age population, vacancies across NHS Scotland and the Care Home sector are increasing and becoming more difficult to fill. Our older population, whilst in many ways are a real asset to our communities – you only have to look at what they deliver in providing care as carers or as volunteers in our local communities – are also being admitted for care in much larger numbers.

So what is to be done; in Boards like Dumfries and Galloway who have a relatively small population, spread out over many square kilometres, it can be a real challenge. But with challenge often comes opportunities. The many areas of outstanding practice that come out of D&G are testament to that. Whether it’s in responding to patient needs from a person centred care perspective or creating innovative solutions to responding to local needs – you only have to look and it’s there. Most of us like to cling on to what we know, but if we look at the health service since its inception, although many aspects are very similar, many aspects of service delivery have changed hugely and we wouldn’t want to go back. The list is endless; infusion pumps to keep people pain free and support a peaceful death, stroke care where people who would have been grossly disabled can literally walk out of hospital within a matter of days, the improved treatment of MIs in specialist areas have transformed the way we now treat coronary heart disease. And of course nursing becoming an all graduate profession is continuing to contribute to improved outcomes for our patients.

So if we are to truly protect our public services and make sure we continue to maintain local services we must embrace change, whilst holding on to what we hold dear; providing truly person centred compassionate care to everybody we care for. Because, although our care may seem routine to us, we never know when that one person we are caring for is at the end of their tether and we are truly the world to them.

I’m confident that we can really have a world class health service but only if we anchor ourselves in what’s important to people, and are creative and bold in our solutions for finding sustainable locally based services.

Fiona McQueen is the Chief Nursing Officer for Scotland