Get up, Get dressed, Get moving by Amy Conley

Think about an older person, someone in their eighties – let’s say it’s your Granma…

Your Granma lives in her own house; she’s not quite so good on her feet anymore, but she gets about OK.  Stairs are difficult but she manages – and she manages to get up and dressed, make her breakfast and her tea, feed her cat, read the paper, get to Tesco in the car with you.

Then your Granma gets ill – she has say, a chest infection.  She is admitted to hospital.  You pack her bag – nightie, toothbrush, comb.  She is admitted to the ward – she is poorly, needs antibiotics and a drip for a few days. So, on goes the nightie and your Granma is in bed; that’s what you do in hospital – you are poorly and tired and you need to rest in bed.

Your Granma is in bed in her single room.  She needs the toilet but doesn’t think she should get up by herself – she is a patient in a nightie so needs help.  But she can’t see very well or hear very well and can’t find her glasses or hearing aids.  She can’t find the buzzer to buzz the nurses and she can’t hear when they are near.   She thinks maybe she could get herself to the toilet, but she can’t see her walking sticks and is scared she will fall. 

Time passes.  Your Granma is incontinent in the bed.  She is embarrassed and frightened – what will the nurses think?

Now she is scared to drink and eat because she doesn’t want to need the toilet and be incontinent again.  And she doesn’t want to bother anyone.  The physio comes to see her, tries to get her up.  But she is still embarrassed and frightened.  She has no clothes to wear.  And she has only those foam slippers she got from the nurse.  So it’s best just to stay in bed.

Your Granma stays in bed for longer and longer.  There is nothing to do.  There is a TV but she can’t see it or hear it without her glasses and hearing aids.   She is getting mixed up now; she can’t remember when she came here or why or what day it is.  She thinks she can see cats in the corner of her room.  She still won’t eat, so she has no strength and feels weak. She doesn’t want to get up.  Her bottom and back hurt.  Her leg has swollen up – they said it is a blood clot.

The physios keep coming back.  They try to get her up; two of them struggle to get her to stand.  She is stuck in bed. 

Your Granma’s chest infection has been treated and she has no acute medical illness, but now she is immobile, confused, dehydrated, incontinent, her muscles are weak and she cannot walk anymore, or get herself washed or dressed. 

Your Granma is not going to manage at home anymore; she has to go to a care home.

 

“GET UP, GET DRESSED, GET MOVING”

At DGRI, we are launching our campaign on Monday 23rd July– the aim is help our patients maintain their function, mobility and independence while in hospital, and for them to return home as soon as possible, as able as possible.

 

WHY HAVE THIS CAMPAIGN?

• Most patients in hospital are over 65
• In hospital, older people spend up to 83% of their time in bed
• 65% of people’s functional ability declines during admission
• 60% immobile older patients in hospital have no medical reason to stay in bed
• If you are over 80, 10 days in hospital ages muscles by 10 years
• 1 week of bed rest equates to 10% muscle loss
• These changes are “deconditioning” –  “reconditioning” takes twice as long

WEARING YOUR PYJAMAS IN HOSPITAL

• Affects your confidence and self-esteem
• Changes how you interact with healthcare staff and other people
• Is usually unnecessary no matter why you are in hospital
• Doesn’t feel very dignified when you are trying to eat your dinner

 

STAYING IN BED IN YOUR PYJAMAS

• Reduces muscle strength
• Reduces confidence
• Reduces function
• Increases blood clots, delirium, pressure sores and infections
• Leads to reduced appetite, low mood and anxiety
• Reduces social interactions
• Lowers pain thresholds
• Can make blood pressure drop
• Causes constipation and incontinence

WHAT CAN HEALTHCARE STAFF DO?

• All of us can and should help patients get moving – nurses, doctors, AHPs, porters, domestic staff, pharmacists…
• Ask the patients how they normally get about and what they normally do
• Make sure patients can access buzzers, water, remote controls
• Encourage patients to get dressed and sit up in the chair

 

WHAT CAN PATIENTS DO?

• Tell us how you normally get about and get things done and what you need to help you
• Try to do things that you do at home – wash and dress, eat and drink on your own if able
• Sit up in your chair and for meals
• Drink lots
• If you can’t get out of bed, do little things – wiggle your toes, do a crossword – every little movement  helps

 

WHAT CAN VISITORS DO?

• Tell us what you do at home
• Bring in glasses, hearing aids and walking aids
• Bring in comfortable day clothes and well fitting shoes
• Encourage you to sit up in the chair and for meals
• Take you for a walk
• Bring in photos, books, puzzles, crosswords

THE BENEFITS

• Speeds recovery
• Reduces time in hospital
• Encourages patient and carer involvement in healthcare and recovery
• Helps to retain patients’ individuality and self-esteem
• Helps patients to quickly return home, mobile and functional

 

If you or your family are worried that it is not safe for you to get up or you might do the wrong thing – ASK US!  We will tell you what is safe and OK for you!

#endpjparalysis

#goinghome

Amy Conley is a Consultant in Geriatric Medicine at Dumfries and Galloway Royal Infirmary

‘What I am told I forget…… by the Renal Team

…what I am shown, I remember.

              …what I do, I understand.’

Confucius was credited with many words of wisdom in his 72-years.  I couldn’t vouch for the authenticity of them all – but if he did utter these words he was indeed a man before his time.

The truth behind these words was apparent to me at our recent Kidney Care Planning Education day. The Kidney Care Planning Service has undergone a bit of a re-incarnation in the last couple of years. Formerly known as the Pre-dialysis service, it is simply the care of patients with an eGFR of less than 20mls/min, as they are more likely to progress to end stage kidney failure and need to plan for such an eventuality. However, the term ‘pre-dialysis’ implies that these people are all heading towards dialysis – when in fact many will choose an alternative path. The younger fitter patients should be hoping to get a pre-emptive kidney transplant from a relative or friend, while some of our elderly, frailer patients may well not benefit from dialysis at all and will survive just as long on conservative (nondialytic) care. So when Tanya Harkness took up the mantle of lead Nurse for the pre-dialysis service, she quite rightly felt a new name was required. Many renal units use the term Low Clearance Clinics, but a straw poll of non-renal staff suggested this was more reminiscent of a rehabilitation clinic for inattentive bus drivers… So, after much discussion amongst the renal team, the more accurately named Kidney Care Planning (KCP) service was born.

The aim of the service remains unchanged and while we do take bloods and treat symptoms, easily 80% of what we do is talk. More specifically we provide as much information as we can to help every person decide which treatment option is going to suit them best. We do this with clinic visits and home visits. We provide information leaflets, website addresses and even YouTube videos – all with the aim of imparting information. Yet still we are sometimes asked a question that blindsides us – that either leaves us thinking ‘How did you not know that from all the conversations we have had?’  or ‘Crikey- that’s a good question that I have no idea how to answer!’ Because at the end of the day none of us handing out this information have ever experienced what they are going through – the actual treatments, the fear and anxiety, the dread of what their lives will become or the understandable desire to block it all out and pretend it’s not happening.

Which brings me back to Confucius! The subject of teaching is vast, with as many different approaches as there are pizza toppings. Yet 500 years BC, Confucius nailed it with this simple truth – when we actually do something, we come to understand it. So who better to teach our patients, than other patients who have been in the same boat.

We have held education days in the past, usually in a hotel function room with talks given by members of staff. Tanya was keen to resurrect the concept, but made it quite clear from the outset that there was ‘No way on God’s earth’ I think was the phrase that she was ‘EVER’ standing up in front of a room full of people to give a power point presentation. (Why not, I have no idea as I am sure she would be excellent….but there we are!)

So a new format was devised between the whole community team – a less formal approach, like an open day, where patients could turn up and wander at will from room to room – talk to the team leads, watch demonstrations, see the equipment and most importantly meet other patients.

The date was chosen to coincide with a visit from Ewen Maclean, Kidney Care UK Patient Support and Advocacy Office, Scotland. Ewen, himself a renal patient, is a mine of information about the support available to kidney patients, grants and how to apply for them and the political landscape that shapes kidney care in the UK.

We no longer had need of a hotel function suite – if there is one thing we are not short of at Mountainhall it’s space! (And the parking is pretty easy too – sorry!!) So, we sent a personal invitation to all our KCP patients, laid on refreshments and opened up the old pre-assessment unit for the day.

The Renal Community Team (Left to right): Fiona Gardiner (Renal Dietitian), Robert McLemon (Transplant) Ian Mottram (Haemodialysis – both home and in-centre), Wendy Brown (Peritoneal Dialysis) Margaret McDonald (Clinic Health Care Assistant & Phlebotomist), Linda Stiff (Vascular Access), & Tanya Harkness (Kidney care planning).

As well as written information everyone had something practical for patients who attended and the responses we had were truly illuminating. Ian had a haemodialysis machine with all the lines and bucket of dialysis fluid set up and received the comment ‘Oh, I didn’t realise it would be so small-I assumed it’d be really big.’ And why not –historically dialysis machines took up a whole room, which must be a really intimidating thought if you are going to be hooked up to one- but it has NEVER occurred to me to comment on the size of a dialysis machine in my many dialysis related conversations.

Robert had asked 3 transplant patients, with more than 50-years of experience between them to attend. I am not sure if any of them showed their scars where the transplant was placed but they had experienced all the ups and downs of transplantation and immunosuppressants so there was no glossing over the bad bits.

Linda was showing patients how to feel  their fistula and what to listen for – explaining how the noise it makes can change if a stenosis is forming – and she was able to give those with a fistula their own stethoscope to involve them in their own fistula care.

Our renal dietitian was also on hand to give practical advice on managing fluid balance, as well as providing visual aids on potassium, phosphate and salt restrictions-something that renal patients universally struggle with!

One of the biggest successes of the day came from Wendy who had persuaded one of her Peritoneal Dialysis (PD) patients & their families to come and chat so they finally actually knew what the PD catheter looked like when it was inserted and could see for themselves how an exchange worked. But more importantly they could ask someone having the treatment what it felt like, how it impacted on their lives, whether it interfered with their sleep, whether it actually helped! One of our patients who had been set on coming to the hospital for haemodialysis when his time comes, has now changed his mind. We have been sure for many reasons that he would be best suited to PD, but fear was driving his decision. One hour watching a gentleman of his own age performing an exchange and listening to his stories of how life continues almost as normal around PD, has achieved what 5-years of reassurance from us could not…

The feedback Tanya received was overwhelmingly positive, but patients are generally nice, so it is the more subtle signs that have persuaded us this is the right approach. The questions and comments patients have since made in clinic prove that they have valued and retained some of the information they learnt that day. One patient commented how reassuring it was to see dialysis patients who looked well and still lived a normal life. And I hope through this some of the fear for the future has abated.

I expect in the future we will still be blindsided by hitherto unasked questions, but it is not only the patients who are learning, as I finish with yet another Confucius quote:

‘He who knows all the answers, has not been asked all the questions!’

We would like to express our sincere gratitude for all the patients and families who came that day, especially for those who came to share their experiences with patients in the early stages of their kidney care planning journey. We are also grateful for the patients who gave their consent for us to take photographs and use them in this blog.  We hope to make “Kidney Care Planning Education day” an annual event from now on.

 

Other useful renal websites:

Patient focussed resources:

Kidney Patients UK / The National Kidney Federation, the largest kidney patient charity in the UK, run by kidney patients for kidney patients, website provides lots of useful information.

Kidney Care UK – formerly the British kidney patient association, very helpful brochures available online.

Think Kidneys – NHS England’s campaign to raise awareness of the importance of kidney disease. Lots of useful resources can be accessed with just a few clicks from this page.

Clinician focussed resources:

Renal Fellow Network – A USA based website with worldwide contributions distilling vast amounts of renal knowledge into bitesized articles, a great resource to start learning about renal medicine.

UKidney – online education on Nephrology, hypertension and kidney transplant.

#NephJC is a fortnightly Twitter-based Nephrology Journal club with visual abstracts, free access to the articles provided by major journals and regularly includes participation by the authors and other worldwide experts in the field.

 

This blog was written by Dr Alison Almond, Associate Specialist in Nephrology, with contribution from rest of the Renal Team, NHS Dumfries and Galloway.

 

Cathy’s Journey by Amy Conley

Friday night, admissions unit is where we first met Cathy……

I say met; we heard her before we met her – Cathy was shouting out, incoherent, clearly agitated. In her room, we found a tiny lady lost in a huge nightie, scrunched up on the bed, clinging onto the bedrail.  Cathy was 95, frightened and distressed.

Cathy had been transferred from another hospital, for assessment of pain.  It was impossible to know if Cathy was in pain or not – she couldn’t tell us.

We looked at her notes…

With a diagnosis of dementia and arthritis, Cathy had been living fairly independently with carer support, hadn’t been in hospital for some years.

A few weeks before, carers worried that Cathy may have fallen, an ambulance was called.  Cathy went to ED – no broken bones, but concern that Cathy couldn’t mobilise safely resulted in admission.

Over the next 6 weeks, Cathy was moved seven times between three different hospitals, from community to acute and back; staff worried about pain, falls and possible injuries, worried they were missing something, worried that more tests were needed…

Over this time, staff reported increasing difficulty with Cathy’s behaviours and confusion; she was distressed, agitated and uncooperative. Other patients were frightened.  Staff felt unable to manage.  Cathy was prescribed sedation.

Cathy by now was very confused, unable to communicate what she needed, not eating, not drinking.  She had become incontinent.

Back to Friday night…….

The sight of Cathy was heart-breaking; crying out, unable to tell us why, unable to understand what we were doing. She was dehydrated, in pain and encumbered by various medical contraptions.

We talked to Cathy’s family.  We decided that Cathy didn’t need any more interventions or hospital moves.  We did our best and made her comfortable.

Cathy died six days later…

 

Cathy, like many people admitted to hospital, was frail; she was frail before she came to hospital that first time.

If we had recognised her frailty at the hospital’s front door and intervened, well, perhaps Cathy’s story might have been different – different conversations, different interventions, different decisions and different plans made.

We talk a lot about frailty but it’s not always easy to explain or to understand.  Frailty is one of those words that get bandied about but what do we mean when we call someone frail?

The dictionary definition is “the condition of being weak and delicate”, something we all feel at times, but not really helpful in identifying frailty in our patients.

Within medicine, after years of vagueness and uncertainty, we have defined frailty as “the reduced ability to withstand illness without loss of function”.

 So……

A minor illness or injury, that would be no more than troublesome to you or I, affects a frail person more profoundly, leaving them struggling to walk, to wash or to dress, to eat or to communicate.

In reality though, how do we recognise the frail patient?  Does it matter?  Does it make any difference?

Age alone does not make people frail – people don’t become frail simply because they live too long.  Frailty doesn’t come with a diagnostic test, but there are signs we can look for – older people, with cognitive problems, mobility problems or functional problems, people on many medications or who live in care homes.  People who present to us with falls, incontinence or confusion.

“Frailty is everyone’s business”

The population is getting older and frailer, particularly here in Dumfries and Galloway.

Older, frail people have higher demands on health and social care services and more unplanned hospital admissions.  Once admitted, frail people are more susceptible to hospital-acquired infections, delirium, nutritional problems, falls and skincare issues.

In comparison to other patients, frail elderly patients are more likely to have prolonged hospital stays, to lose their mobility and functional abilities; they are more likely to be admitted to residential care, more likely to die.

I am a geriatrician.  I’m not at the glamorous end of medicine and I don’t have a bag full of fancy equipment, tests and treatments.  But within our medical specialty, we do have one intervention that has been shown to improve outcomes for the frail elderly –Comprehensive Geriatric Assessment

CGA means that frail older people are much more likely to be well and living at home 12 months after admission, and much less likely to be admitted to care homes or to die within those twelve months.

CGA is a multidisciplinary assessment of a patient and their physical, psychological and functional needs.  It allows us to develop a personalised, holistic and integrated plan for that patient’s care, now and in the future.  We think about how patients walk, talk, eat, drink, see, hear, think, remember, socialise, mobilise, and take their medications.  We think about how we can make all of those things better and easier for frail elderly people and their carers and families.

We all need to understand and recognise frailty.  Think about it, see it and talk about it, and allow a person’s frailty to influence decisions for their care and future.

Over 18 months we are working collaboratively with other health boards and Health Improvement Scotland to improve recognition of frailty at the front door.

Hopefully, if we get it right we can influence a better outcome, one that recognises and considers the specialist needs of our frail elderly people, one that supports them to continue to live happily and safely in a place that they can call home…

 

“We’ve put more effort into helping folks reach old age than into helping them enjoy it…”

Frank A. Clark, American Politician 1860-1936

 

If you have an interest in frailty and want more information or to become involved in our project please contact   amy.conley@nhs.net or lorna.carr2@nhs.net

Amy Conley is a Consultant in Geriatric Medicine at Dumfries and Galloway Royal Infirmary.

 

 

 

 

Take Two Bottles Into The Shower? Not me, I’m a Clinical Health Psychologist by Ross Warwick

Because you’re worth it

Bang! And the dirt is gone!

Eat fresh

I’ve been thinking a lot about advertising these past few weeks as September is a significant time for my team in Clinical Health Psychology. This month we will be making a concerted effort to promote our service, raise our profile and increase our contact with the people we aim to help.

As part of this, Ken has kindly allowed us to take over the blog for a few weeks. I’m kicking things off with an account of what the service does and I thought I would take inspiration from psychological tricks used in the world of advertising to help draw you in and get the message out there.

I’ll start, then, with a summary of the service that follows the advice of a Professor of Experimental Consumer Psychology at the University of Wales, Jane Raymond. Prof Raymond advises that rather than bombard the audience with information I should break it into chunks to allow the brain time to process each component:

• Chunk 1: The Clinical Health Psychology service helps people who have a psychological problem that is caused and maintained by a physical illness.
• Chunk 2: These problems usually involve unpleasant feelings and unhelpful thoughts about the illness that keep someone from doing things that matter to them.
• Chunk 3: This can cause distress, affecting overall well-being, medical treatment, self-management and health outcomes

An article in a social psychology journal showed that a wide range of people respond well and are persuaded by stories (Thompson and Haddock, 2012). So to illustrate chunks 1-3 here’s a fictionalised case based on real events:

“Jane is a young teacher who has type 1 diabetes. Her condition and the things she must do to keep on top of it are often accompanied by feelings of shame, anger and loneliness. She has frequent thoughts that her condition means she is abnormal and that it must be hidden from others. Because of these unhelpful thoughts and feelings she avoids testing her blood, guesses her insulin levels, is inconsistent with her diet and keeps problems to herself.

She has been absent from work and in and out of the DGRI several times within the past twelve months. Because of this she believes friends, family and colleagues are annoyed with her for not taking proper care of herself and landing them with more responsibility. As a result, she avoids seeing people and has become more and more isolated.”

The next steps for Jane are chunked below:

• Chunk 4: In therapy we would work with Jane to live well with her condition by addressing her unhelpful thoughts, feelings and avoidant behaviour
• Chunk 5: As therapy is all about collaboration, Jane’s most likely to have a good outcome if she’s motivated to participate and make changes to her life
• Chunk 6: Jane can be referred to Clinical Health Psychology by anyone who is involved in her care, be it her GP, Practice Nurse, Dietician, Diabetes Specialist Nurse or Consultant.

In Jane’s story, she’s in and out of DGRI because thoughts and feelings stop her from acting in a way that would help keep her well. So psychological therapy would add value by reducing her distress and unplanned contact with services (and by highlighting that sentence your attention has been focused on a key message about how psychology makes a difference to both the person and the hospital; Pieters and Wedel, 2004).

But would you believe that individual therapy expertly delivered by members of our experienced, compassionate, and, yes, attractive, team is but one feature of our service? In Clinical Health Psychology we also provide training, teaching, supervision and consultation because you don’t need to be a psychologist to provide psychological care (worth mentioning because (a) it’s completely true and (b) according to Goodman and Irmak, 2013, audiences are likely to prefer multi-featured products).

Already the Diabetes and Cardiac Teams are benefitting from increasing their psychological knowledge and skill through participating in Emotion Matters training, and a group of local GPs have recently completed training to introduce CBT techniques into their routine consultations. Recruitment of a second cohort will be underway soon.

Time for pictures of the product:

By now thanks to my evidence-based and scientifically informed techniques of persuasion, you will no doubt want to know how you can benefit from working with our wonderful service.

You can contact us by email or by calling us at the psychology department to talk about matters psychological, be it complex cases, potential referrals, or training your department. Find out more about making referrals by consulting our service leaflets which are available absolutely FREE through Beacon by searching for ‘Clinical Psychology’ or looking under ‘Documents’ after following the link below. And as the Patient Information Leaflet can also be found there, you enjoy a 2 for 1 bonus!

http://hippo.citrix.dghealth.scot.nhs.uk/sorce/beacon/?pageid=Sitesearch&searchCriteria=clinical%20health%20psychology

Keep your eyes open for opportunities to attend training events we’re delivering this month and enjoy the blog posts written by the Clinical Health Psychology team over the next few weeks. Finally, to eke this advertising ruse out just a little further, comment below to be part of a Clinical Health Psychology virtual focus group.

Just do it.

Ross Warwick is a Consultant Clinical Health Psychologist and Lead for Clinical Health Psychology at NHS Dumfries and Galloway

Can I make a difference? by Paul Gray

It’s a big question – can I make a difference?  How does it feel to ask yourself that?  For some of us, the answer will be different on different days.  My experience suggests that your answer depends much less on what you do, than it does on how you feel.  In this blog, I’d like to offer some thoughts on making a difference.

However, some context first.  I fully recognise the challenges we face.  Health budgets are going up – but pressures on recruitment, and the demands of an aging population, are also very real.  There is also still much to do in tackling inequalities, and improving the health of the population, which NHS Scotland can’t do on its own.  And we do know that people have the best outcomes when they are treated and cared for at home, or in a homely setting.  So our current models of care are transforming to meet these demands, and to provide the most appropriate care and treatment for people, when they need it, and change brings its own challenges.

So my first suggestion is to turn the question, “Can I make a difference?” into a statement – I can make a difference.  If you start from that standpoint, you’re much more likely to succeed.  It’s easy to become pre-occupied with the things we can’t change, and the barriers and problems – I know that I fall into that trap from time to time.  But wherever I go, I see people throughout the NHS, and in our partner organisations, making a difference every day.  So ask yourself, what is the one thing I can do today that would make a difference?  And then do it!

Now, give yourself some credit – think of an example where you did something that was appreciated.  Write it down and remember it.  If you’re having a team meeting, take time to share examples of things that the team did, that were appreciated by others.  Sharing these examples will give you a bank of ideas about simple things that matter to other people.  And it also gives you something to fall back on, if times are tough.

Next – think of an example when someone did something for you, which you appreciated.  Find a way to share these examples too – if it worked for you, it might work for someone else as well.  Ask yourself when you last thanked someone for something they did well, or something you appreciated.  It’s easier to go on making a difference if others notice what you’re doing!

If you’re leading or managing a team, ask yourself how much time the team spends discussing what went well.  It’s essential to be open and transparent about problems and adverse events, but if that’s the whole focus of team discussions, we overlook a huge pool of learning, resources and ideas from all the positive actions and outcomes.  And we risk an atmosphere where making a difference is only about fixing problems, rather than about improvement.  So, as yourself and your team, what proportion of time should be spent on what went well?

Remember to ask “What Matters to You?”.  I know that the focus of this question is on patients, and that’s right because they are our priority, but it’s a good question to ask our colleagues and our teams as well.  Just asking the question makes a difference – it gives you access to someone else’s thoughts and perspectives, and is likely to lead to better outcomes.

Will any of this change the world?  Not on its own, of course.  But you could change one person’s world, by a simple act of kindness, or listening, or a word of thanks.  You can make difference!

Paul Gray is the Chief Executive Officer for NHS Scotland and the Director General for Health and Social Care at the Scottish Government

Honest Reflections by Barbara Tamburrini

As this is now the third blog I have written for DGHealth, either there is a shortage of ‘willing volunteers’ or others have found better ways to say “maybe, possibly, perhaps soon” to Ken Donaldson when his charming request drops in the email ‘in-box’. Whatever the reason, I find myself agreeing to contribute and construct another brief moment of interest in our increasingly busy days. Having written previously about handover processes and the importance of good communication, I thought I would flip this on its head for this blog and consider the ‘inward’ communication reaching our ears from eager and sometimes over-active media sources and outlets.

A scan of headlines published over recent times don’t make happy reading for hard-working and dedicated NHS employees trying their best to simply ‘stay afloat and fight the fire’. Over the last 4 days, a number of reports sum up the general gist of current NHS news:

• 9^th Feb 17 – “Worst A&E waits ever, leak suggests” – BBC News
• 8^th Feb 17 – “The NHS and its crisis: Myths and realities” – Sky News
• 7^th Feb 17 – “Scotland’s A&E departments miss key waiting time targets over festive period” – Daily Record
• 7^th Feb 17 – “Maternity services in Scotland ‘beginning to buckle’” – BBC News
• 7^th Feb 17 – “Ageing UK midwife workforce on ‘cliff edge’, warns RCM” – Nursing Times
• 7^th Feb 17 – “NHS [Scotland] cancels 7740 operations due to lack of resources” – STV News
• 5^th Feb 17 – “Scotland patients waited more than a year for hospital discharge” – Sky News
• 5^th Feb 17 – “Revealed: The hidden waiting list scandal for Scotland’s NHS” – Sunday Post
• 5^th Feb 17 – “Growing waiting times threat to NHS” – BBC News

The recent coverage by the BBC assessing the state of the NHS across the UK in their NHS Health Check Week raised issues including a perception of desperate times inside A&E departments, analysis of patient flow reducing to a halt and “clogging up” hospital wards and frontline services being radically changed in attempts to overhaul health provision in the wake of the publication of NHS England’s five-year plan for the NHS in 2014. Indeed, as recently as 15^th January 2017, chair of the BMA, Dr Peter Bennie was quoted as stating the Scottish NHS was “stretched to pretty much breaking point” and “heading for a breakdown” unless the government acknowledge the disparity between the current comprehensive service provision and existing funding levels.

So what does all this mean for humble workers ‘at the coal face’ and patients who so desperately rely on the NHS and our contribution within it? Dr Bennie wisely points out that honesty is required when assessing all elements of our much loved but potentially deeply troubled NHS. Honest reflection on our actions and behaviours as NHS staff is required to ensure we are all maintaining a focus firmly centred on our patients and clients. In a profession which is becoming more and more challenging with morale which seems to be ebbing lower and lower, can I really state with certainty that my focus is always upon my patients?

If I am looking at my last shift on duty, as part of the DGRI capacity team, I know that the greatest majority of my time was spent considering patient care but, the complexities of the work involved in capacity management mean a constant ‘juggle struggle’ between complicated discharges, patients keenly attending for their long-awaited surgery and fast and furious emergency admission rates with significant staff shortages thrown in to make life really interesting. This is a really difficult environment to function effectively, positively and proactively.

Its exceptionally difficult to have to say “I’m really sorry but I don’t have anyone who can give you a hand at the moment” to hard-working and struggling colleagues whom you respect and want to help. This inevitably influences work-focus and morale, sometimes away from patients and onto less fruitful, less important areas – we’re only human after all! I’m sure many of you reading this blog can identify with this and acknowledge that there can be times when we recognise that our concentration has slipped away from the real reason we are all here. This honest reflection is being actively encouraged in nursing through the revalidation process which will positively impact the profession in the future with a similar process in place for medical staff.

Honesty is also required from patients and clients using NHS services with individual ownership of health and the impact of lifestyle choices upon this of fundamental importance. The vast majority of NHS patients freely and actively claim this responsibility but this is not always the case in some crucial clinical areas like Emergency Departments. For the headlines to stop, the public also need to do their part. In a recent article in Glasgow’s ‘Evening Times’ (9^th January 2017), it was stated that around 1 in 6 Scottish ED attendances may be unnecessary at a potential cost of £33 million and whilst ministers have provided responses aimed at removing any punitive element and reassuring the public that they are right to be concerned about their health, this concern needs to be correctly channelled for current pressures on health services to be eased. Patients with 3-month history of injuries, minor ailments which could be assessed elsewhere and those telling us they didn’t bother trying their GP as “they wouldn’t get an appointment anyway” are all too frequent presentations in busy ED’s. In my ‘other role’ as an ANP in ED, every time a patient told me this, I called the surgery myself and was given an appointment that day for their patient so, as well as accepting ownership of their own health, patients and service-users also need to be well-informed, confident and comfortable about the health services they access and when they utilise these valuable resources.

My feeling is that an organisational honesty also exits within current healthcare with ‘the powers that be’ having a responsibility to consistently and carefully examine the healthcare delivered with rectitude and reliability. We are somewhat fortunate in that we have an organisation who actively engages with staff through measures such as #ontheground, weekly core briefings, active and lively facebook and twitter accounts and the informative and interesting DG Change website (http://www.dg-change.org.uk). Indeed, this weekly blog also serves as a useful interactive communication with reflections and comments on posts actively encouraged. But is this enough? I would argue that even though these proactive measures exist in NHSDG along with many other approaches, staff morale remains low in some clinical areas and sickness absence rates are running well above optimum levels in some departments. So, are the current measures of engagement between the organisation and its employees inaccessible, uninteresting or unimportant to some staff, not effective enough, not addressing the correct issues or simply not delivering the desired impact? Although impossible to answer within this blog, the significance of this question and the consequences associated with it, must remain high on the agenda if staff empowerment, engagement, motivation and morale are to be maximised as we hurtle head-long towards a new hospital and evolving chapter in our healthcare provision.

Every ward I go in to during my capacity shift has AHP’s, nursing and medical staff who look tired, strained and burdened by an ever-increasing workload with constant financial and resource pressures making the job all the more difficult. But, and this is crucial, staff continue to come to work to do the best job they can given these constraints. They continue to change rota’s to cover absences, work through breaks and past finishing times to help their colleagues and patients and they continue to ‘fight the fire’ with dedication, sometimes in the face of adversity. Healthcare staff MUST care about the service they provide, to deliver care which remains meaningful, appropriate, safe, effective and patient-centred.

Whilst we as staff have a responsibility to continually reflect on our own practice, this must be fully supported, actively encouraged and consistently underpinned by honest reflection at a strategic level on the current ‘state-of-affairs’ and how this can be promoted and enhanced within the existing inflexibility of financial austerity.

Therefore, returning to our news headlines, what does the future hold for the NHS locally and nationally? Locally, despite considerable challenges, there are exciting times ahead as we look to fully embed health and social care integration and also move our main hospital services into our new build. Nationally, the picture is less clear with ever-increasing financial pressures being placed on continually growing workloads in a society with greater demands in terms of health due to conditions such as obesity, diabetes, heart and respiratory diseases. This is compounded by an ageing population sometimes presenting with chronic conditions which one simply did not survive from a decade or two ago.

hould we as NHS employees, the general public, healthcare service providers and users be concerned about the growing tide of negative headlines? Perhaps. Maybe these give an insight into the ‘health of our NHS’ – gosh, that’s a worrying thought. Or maybe, we now live in an environment feeding off news negativity and scandal in which we have all become de-sensitised to minor challenges therefore pushing media providers to ‘raise-the-bar’ in their reactionary reporting of our beloved NHS which would have, until relatively recently, been ‘off-limits’ to the eager reporter looking for a scoop however vague, misleading or sensational.

Lets return to our honesty theme. Within this blog, I have suggested that some honesty is required in our NHS and this should also extend to the reporting of challenges and issues to a certain extent. The antonym to sensationalism, where bad, critical or damming NHS news is forbidden with offenders punished by a stint taking minutes for certain western hemisphere parliamentary press conferences, is also not good for contemporary healthcare since this stifles and prevents honest reflection from which, lessons can be learned and development thrives.

There is every likelihood that the headlines wont go away and they may even increase in frequency or adversity. Perhaps though, if we all contribute in our own way, positive, honest and transparent analysis at individual, peer, organisational and national level will drive, develop and sustain an NHS we are all proud of and which we want to protect, however difficult or complex the discussions and decisions.

Barbara Tamburrini is an Advanced Nurse Practitioner at NHS Dumfries and Galloway

 

 

I am human by Dawn Renfrew

“I am human: I think nothing human alien to me”

Terence the African

So wrote Terence the African, around 2000 years ago. He was a slave from Roman Africa, a dramatist, and an interpreter. He was quoted recently in the annual BBC Radio 4 Reith lectures, by Professor Kwame Anthony Appiah, professor of philosophy and law at New York University.

Appiah Now

Professor Appiah’s subject, “Mistaken Identities”, is one of the most defining issues of our age. We all have multiple identities which describe who we are. These include those suggested by our gender, age, occupation, political affiliation, nationality, race etc. The possibilities are endless when you think about it: parent, child, sibling, friend, Bake-off fan, or Queen of the South fan are just a few.

In a healthcare setting, we also have many identities, including being part of our own discipline, team, ward or service. Sometimes we are ourselves patients, and some of us are managers. Any health condition, whether physical or mental, can become part of our identity.

Appiah himself embodies many complex aspects of identity. Half-British, half-Ghanaian, he was brought up in Ghana and England, and has now adopted America as his homeland. He is the grandson of the Chancellor of the Exchequer, Sir Stafford Cripps. He is a crime novelist, and a fan of Japanese haiku. In addition, he was one of the first people to take advantage of the new gay marriage laws in New York State. He is probably ideally placed to set about unpicking assumptions which we all have about the “labels” associated with identity.

Growing up in England

Appiah discusses 4 aspects of identity over 4 lectures: creed [religion], country [nationality], colour [race] and culture [Western identity vs non-Western]. These are delivered in 4 different locations: London, Glasgow, Accra [capital of Ghana] and New York. The lectures cover the great sweep of history, and examples from a range of countries across the globe. They argue that identities are more complex and fluid, than are commonly supposed. They are more a “narrative”, than an “essence”, and do not necessarily determine who we are. Everywhere you look, you can find exceptions in identities, which challenge our commonly-held assumptions about them.

Growing up in Ghana

Identity is important for our survival. It helps give meaning to our lives, and helps us feel, and be, part of a community. Evolutionary psychologists would argue that it has been critical to our development as a species. All identities are constructed and evolve over time, but as soon as you construct an identity, you create potentially not only an “us” [those within the group], but also an “other” [those outside it]. When there is competition for resources, things can turn nasty, and the “others” may be persecuted or scapegoated. So it is important that we are relaxed and open about our identities, and that we recognise why that process of “othering” arises so easily within all of us. It’s a trap that is easy to fall into, and we need to resist it.

Appiah doesn’t mention healthcare in particular. But if we apply these ideas to the healthcare setting, we can see that a shared identity can help us pull together to meet our patient’s needs, in what are often increasingly challenging circumstances. Equally, there can be a process of “othering” which operates, whether it is towards our patients, our managers, our employees, or other agencies. Whilst understandable, “othering” can prevent us fully engaging with the “other” in a way that leads to the best outcome for all of us. This is relevant to our aims to provide person-centred care, and to integration with other agencies.

On the question of nationhood, Appiah isn’t against nationalism, so long as it is an “open, civic nationalism”. His favourite idea of nationhood, however, involves 2 concepts. The first is patriotism, defined as concern with the honour of your country [or countries]. This means feeling proud when your country does something good, and ashamed when it does something bad. The second concept is cosmopolitanism, which means being a citizen of the world. These can combine to form a “patriotic cosmopolitanism”. You can, and should, respect both “the local” and “the global”.

Identities connect the small scale, where we live our lives alongside our kith and kin [and healthcare colleagues], with larger movements, causes and concerns. Our lives must make sense at the largest of scales as well as at the smallest. We live in an era where our actions, both ideological and technological, have global effects. When it comes to the compass of our concern and compassion, humanity itself is not too broad a horizon. We live with 7 billion other humans, on a small, warming planet. The concept of cosmopolitanism has become a necessity.

Appiah with Obama

Appiah argues for a tolerant, pluralistic, and diverse society. He says, failure to accept this is not just a failure to understand human identity, it is not in our collective self-interest. We do not need to abandon identities, but we don’t need to be divided by them either. Ultimately, the identity of “being human” ought to transcend all others.

As Scout, the young heroine in the novel about race and mental illness, To Kill a Mocking Bird, concludes: “I think there’s just one kind of folks. Folks”.

The Reith lectures are available to listen to on the Radio 4 website, indefinitely.

Dr Dawn Renfrew is a Consultant Child and Adolescent Psychiatrist for NHS Dumfries and Galloway

To Err Is Human by Maureen Stevenson

‘To Err Is Human’, to cover it up or fail to learn unforgiveable

It is now nearly 20 years since the Institute of Medicines (IOM) seminal work ‘To Err is Human: Building a Safer Health System’, raised our collective conscience about the scale of harm in healthcare and that the majority of factors that give rise to error are systemic in nature.

As we take our first tentative steps into 2017 and begin to think about how we might improve our work, work off those excess pounds and gain a new level of fitness and wellbeing (or maybe that’s just me!) it is important to reflect what has been achieved and what we will take forward into 2017:

• A new Hospital
• Integration of Health and Social Care
• Development of a local Quality Improvement Hub

Whilst these might be strategic in nature there are many equally worthy service, team and individual achievements to be proud of, each one of them contributing to the wellbeing of many thousands of people, families and communities.

On a personal note I was very humbled to be able to accompany my Mum to an Alzheimer’s Scotland Christmas Tea Dance. In my head I had so many other callings on my time and attention, I rushed from a meeting straight into ‘the hokey cokey’ to truly learn ‘what it’s all about’ – people, compassion, caring and having fun. Wouldn’t it be lovely to retain that special feeling all year and to remember why we do the work that we do?

My blog today is about Human Factors. Human Factors (Ergonomics) i.e. the study of human activity (inside and outside of work). Its purpose as a scientific discipline is to enhance wellbeing and performance of individuals and organisations. The key principles are the interactions between you and your environment both inside and outside of work and the tools and technologies you use.

In my role as Patient Safety and Improvement Manager I have the great privilege of supporting individuals and teams to develop the capability to improve the quality, the safety and effectiveness of care. However, I also oversee our adverse event and learning systems which all too often highlight the failings in our systems and in our interactions with those sometimes very complex systems. Human Factors and ergonomics offers an opportunity for us to understand the interactions of humans working within often imperfect and messy systems. People who most of the time make the correct choices and decisions in difficult situations with incomplete information to help keep patients safe.

New thinking suggests that we should look at the actions and decisions that help keep patients safe and not only those that result in harm. If we were to support teams to understand the thinking and the behaviours that keep people safe we might enable a more resilient workforce able to vary their response to challenging situations.

Often the design inputs and processes related to the workplace fail to adequately take account of human abilities and characteristics, making it inevitable that failures will happen (and happen again). We know that many patient safety incidents across all health and social care sectors are directly related to a lack of attention to Human Factors issues such as the design of everyday work tasks, processes & procedures; equipment and technologies, organisation of work and working environments.

We would all agree that safe care delivered to a high standard is what we look for in a health and social care setting, and most of the time we achieve just that. Tremendous gains have been made in eliminating infections from our Intensive Care Units by standardising work practices and improving team communication. Improvements in Medicines Reconciliation have been seen across Primary and Secondary Care and work is currently underway to reduce pressure ulcers across our care system but how can we simultaneously improve efficiency and effectiveness and care that is delivered in a way that considers the needs of the recipient and the caregiver. Might a review of Human Factors help?

Human Factors (Ergonomics) can contribute to achieving this as it involves learning about our characteristics as humans (e.g. our physical size or strength, how we think and how we remember things), and using that understanding to improve our well-being and performance through the type of work we do, the tools and equipment we procure to do it and who we do it with.

The environment, the culture, our communication processes and leadership impact on system performance as they impact on how people perform. Understanding how improvements in one part of our system might be spread elsewhere will require careful attention to all of these factors.

To achieve a culture that is just and fair we have to take account of Human Factors, we need to understand what safe, effective person centred care looks like and be able to replicate the conditions that enable it to survive and thrive.

I’d like everyone’s Mum to experience the joy of care, apparently effortlessly given that accounted for her health, her care and her emotional needs. I’d like to extend a huge thank you to all the health and care staff and volunteers who together make that possible in very difficult circumstances.

My ambition for the year ahead is for us to become more proactive in our pursuit of safety , to understand what we might learn from when things work well and how that might impact on how we support individuals and teams to learn and continually improve. Safety II as this shift is being referred to will require a shift in our thinking and in how we behave. The table below highlights how we might begin that shift from Safety I to Safety II.

As humans we bring our whole self to work, so let us use all of our resources and resourcefulness to enhance the safety and the experience of care. Nothing is more satisfying than bringing joy to those you work with whether they be your co workers or the patients and their families you care for.

Maureen Stevenson is the Patient Safety & Improvement Manager at NHS D&G

 

Daily Dynamic Discharge (DDD) by Patsy Pattie & Carole Morton

“Daily Dynamic Discharge is to improve the timeliness and quality of patient care by planning and synchronising the day’s activities”.
(The Scottish Government, Edinburgh 2016)

The 6 Essential Actions for improving unscheduled care was launched in 2015. The 6 actions were identified as “being fundamental to improving patient care, safety and experience for the unscheduled pathways”. One of these actions is “Patient Rather Than Bed Management”. This approach requires the multi disciplinary team working together to plan and synchronise tasks required to ensure a safe dynamic discharge process, aligning medical and therapeutic care, discharge earlier in the day and transfer back to the GP in time, reducing the length of stay in hospital.

Why do we need it?
The recent day of Care Audit in September 2016 indicated that 30.5% of patients in hospital beds did not require acute hospital care. These patients should have been transferred to another area for continued care or discharged home.
For some health professionals, too many conflicting demands on time often results in optimising work in such a way that may seem logical to the individual, especially if you are covering across wards, but may not be optimal for patient flow. This mis-synchronisation can cause delays and increase the length of stay for patients. Where there is a clear priority of order of tasks for that day, each individual team member plays their part in ensuring the priority tasks for patients is actioned or completed, which works for the patient, thus reducing delays in discharge or transferring the patient.

Who is doing it?
Ward 10 was nominated as the Exemplar ward for DGRI and implementation commenced in early September 2016. Early indications show that time of day discharges are taking place earlier in the day around mid afternoon. Prior to the introduction of DDD 27% of patients had been discharged by 4pm, in the four weeks since implementation the figure has almost doubled to 49%.

When are we doing it?
Each DDD ward huddle usually takes place at 9am each morning. Some wards have incorporated a DDD catch up meeting into their afternoon handover huddle.

What are the benefits?
The DDD approach promotes proactive patient management for today and preparing for tomorrow’s activities i.e. increase accuracy on our discharge position and increase awareness of the need to create capacity at key points throughout the day.
This is aligned to The Royal College of Physicians acute medical care “The right person, in the right setting – first time” (please see link below).
https://cdn.shopify.com/s/files/1/0924/4392/files/acute_medical_care_final_for_web.pdf?1709961806511712341
A recent quote from Vicki Nicoll, SCN ward 10:
“DDD for us has had such a positive impact on the ward as we are finding patients are being seen by all members of the Multi Disciplinary Team (MDT) in a timelier manner.  The patients are being discussed rather than going from one weekly Multi Disciplinary Team meeting to the next.  Interventions are being done more timely from all members.  We have noticed that length of stay has reduced and patients that you would normally presume would be with us for some time seem to be getting home quicker. We recently had a patient who was a complex discharge and I personally thought the patient would have passed away in the ward, but everybody pulled together and we were able to return the patient home.  Sadly, she passed away at home, where she wanted to be with her family”.

“DDD has taken away the thought that nurses should do everything when in fact it is everyone’s job to work together to ensure that the patient is on the right pathway”.

DDD is currently being rolled out to most of the acute wards in DGRI and a test of change commenced on 21st November in Annan Community Hospital. Implementation at the Galloway Community Hospital is planned for mid December.

We all have our part to play in the planning of a safe discharge for our patients, DDD enhances our current processes, promoting an MDT approach with teams working collaboratively and more robustly.

Patsy Pattie works in the Acute Services Improvement Team and Carole Morton is an Assistant General Manager Acute Services for NHS Dumfries and Galloway

Island reflections by Heather Currie

Holidays are for fun, relaxation, recharging the batteries, catching up, all things good. But holidays also give time to think and reflect and often holiday situations trigger a thought which may have relevance to a work situation. I think that’s ok, I don’t think I’m pathologically workaholic. I enjoy having time to reflect, whether that be on holiday or other.

A recent holiday in the beautiful west coast, triggered reflection on how we respond to patient’s needs, and perhaps how we could do better.

On the west coast of Mull is a ferry which goes to the tiny island of Ulva. While waiting to take a boat trip out to the Treshnish Isles (home of a huge colony of wonderful puffins), I noticed the sign indicating how to summon the ferry. No regular routine service, just a board with a moveable cover. Move the cover, red board shows, ferryman on Ulva sees red board, ferry sets out. Simples.. Ferry there when needed and when summoned. Receptive and responsive. It made me think whether or not we are receptive and responsive to our patients’ needs and what about the needs of the relatives?  A few examples make me think perhaps not enough?

In recent times my mother in law sadly suffered from a stroke and was in an acute hospital for several months before being transferred to a Rehab unit and subsequently a nursing home. Being a patient is always a humbling and learning experience, as is being a relative and visitor of a patient. On one visit I was concerned that her finger nails were quite long and dirty. “Mum” could not speak at this stage but since she was always very particular about her appearance, I knew that this would cause her distress and asked the nurse in charge if it was at all possible, please please, thank-you so much…(it felt like asking for anything was a major challenge) could her nails be cut. To my surprise and disappointment, I was told that this was not possible since only two nurses on the ward had had the “training” and when they were on duty it was unlikely that they would have time. Receptive and responsive or too rigidly bound up in rules and protocols of questionable evidence base that basic needs are not met? Thereafter we took it upon ourselves to cut the nails ourselves!

I was very reassured on return to DGRI that this would not happen here and strongly believe that we are more receptive and responsive, but could we do better?

Recently, one of our gynaecology patients who had been diagnosed with a terminal condition was moved between wards four times as her condition deteriorated. As long as her medical and nursing needs were being met, was it fair on her at this sad stage to have so many moves? Did we really think about what was best for her and her family and were we receptive to their needs?

In outpatients, how often do we ask patients to return for a “routine” appointment when they may not need to be seen in six months time, but have problems at a later date? Could we instead be able to respond to their needs and see them or even make telephone contact when really needed?

An elderly gentleman understandably complained because he spent a whole day travelling from the west of the region to Dumfries by patient transport, for a ten minute outpatient appointment to be given the result of a scan. In his own words, “he was not told anything that could not have been told by telephone”.

What routine investigations do we carry out that are of limited clinical benefit, often subjecting patients to yet further unnecessary investigations because of slight irrelevant abnormalities?

When questioning our practice, let’s also be prepared to be curious about that of others in hospitals to which we refer—recently a patient was referred to Glasgow for a gynaecological procedure. The procedure went well but the patient subsequently contacted me concerned that she had been asked to return to Glasgow for a follow up discussion. She wondered if a phone call would be possible in view of the huge inconvenience that this appointment would cause. I wrote to the consultant and asked if this would be possible. His rapid response was enlightening and reassuring: he had always brought patients back to a clinic as routine practice and never considered an alternative. He promised that from then on he would offer all such patients a telephone follow up instead.

Let’s use common sense and be prepared to challenge and bend the rules. Remember the ferry. While we do not have a “ferryman” waiting to respond at all times, we could consider the 4 “Rs”and be –

Responsive not Rigid,

Receptive not Routine.

Heather Currie is an Associate Specialist Gynaecologist and Clinical Director for Women and Sexual Health at NHS Dumfries & Galloway