Improving Patient Flow by Chris Isles

Dave Pedley gave an excellent talk two Wednesdays ago on Tackling Crowding in Emergency Departments, triggered no doubt by the number of times recently we have been running at 100% bed occupancy with patients sitting in chairs in the Emergency Department because there were no free cubicles.

The nightmare scenario for us all as the clock ticks inexorably towards December 2017 is that the same thing happens when our fabulous new hospital opens and the TV cameras, newspapers and journalists begin to salivate at the prospect that something goes wrong (there will be no story to report if the transition to the new hospital goes smoothly and there are no corridor patients).

The chances that something could go wrong are actually quite high and the problem is almost entirely medical by which I mean the large number of frail older people living precariously in the community who fall, become immobile, incontinent or delirious and require at least some form of assessment but often admission to hospital.

The omens are not good.  Dumfries and Galloway has the second highest proportion of people in Scotland who are aged 75+ and living alone.  Our Health Intelligence Unit have shown that despite numerous initiatives and new ways of doing things the Medical Unit would be sailing perilously close to 100% bed occupancy if we moved into the new hospital today. (See me previous blog on the new hospital here)

During his talk Dr Pedley showed a powerful 5 minute video by Musgrove Park Hospital in Somerset entitled Tackling Exit Block ie their hospital’s inability to move patients through ED because of numerous interrelated system failures.  (https://youtube/WX1YwKIkWzA).  Musgrove Park ‘s Top Ten Reasons Why People Cant Leave Hospital were as follows:

  1. Discharge delayed so patient can have lunch
  2. Carer/relative can’t pick them up till after work
  3. Nurses too busy looking after other patients to arrange discharge
  4. Waiting for transport or refusing to leave without free transport
  5. Waiting for pharmacy
  6. Waiting for ward round
  7. Waiting for blood or scan results
  8. Waiting for discharge letters
  9. Packages of care planned for late afternoon/early evening
  10. Patient doesn’t want to go to the assigned bed in community hospital

During discussion a number of solutions to our own recurrent difficulties with patient flow were proposed.  These included tackling all of the above in addition to attempting to educate the public about when and when not to attend ED.  My own view is that this might be as fruitless as King Canute sitting in his throne on the beach and attempting to stop the incoming tide on the grounds that any patient who comes up to ED and is prepared to wait up to 4 hours and possibly more to see a doctor or a nurse must feel they have a very good reason to be there (one often quoted reason being that they could not get an appointment to see their GP).

There were some illuminating moments.  We asked Patsy Pattie whether Dynamic Daily Discharge was still as effective as it had been when it was first rolled out.  She replied that some wards needed support on embedding the process.  Dr Pedley praised staff for their firefighting skills on those occasions when patients were unable to access cubicles in ED which prompted Philip Jones, our chairman, to say that a corporate rather than firefighting response was needed.  Many heads nodded in agreement.

A corporate response might mean fixing lots of little things in order to make patients flow through the system more speedily.  Dynamic Daily Discharge could then become an established part of ward routine rather than an optional extra; the paperwork in the medical assessment area might need to be simplified to allow nurses to move patients into the body of the ward more quickly; a nurse on each ward might be designated to carry the ward phone rather than allow it to ring endlessly in the hope that someone else will pick it up; clinical teams would actively consider how patients might get home;  consider community detox for alcohol withdrawal; patients earmarked for discharge might move to the dayroom unless physically unable to do so; hospital taxis might take people home if relatives or patient transport cannot do so; patients could be issued with a prescription to take to their local pharmacy if new medications are required or go home with immediate discharge letter to follow if not.

To these solutions I would add fully funded Ambulatory Emergency Care and Comprehensive Geriatric Assessment services together with more and better social care and a commitment to fill the hospital with more staff on public holidays (of which there will be four within one month of the new hospital opening).

The Chief Executive of Musgrove Hospital finished her contribution to the Exit Block video by saying ‘we need every single member of staff to understand their responsibility in ensuring patients flow through our hospital so that we can discharge them home as quickly and as safely as possible’.  Who could disagree?

Professor Chris Isles is Sub-dean for Medical Education and is a Locum Acute Physician.

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.

maureen-1As 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.

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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

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There is no truth, only Perception by Emma Murphy

I recently started as the new Patient Feedback Manager for NHS Dumfries and Galloway. Just as I was settling in to my new role, life popped a little bump in the road and I found myself rushing through the doors of A&E one Friday morning with my poorly toddler. After a number of tests and assessments we found ourselves on Ward 15 for the weekend. I’m usually a reasonably laid back parent and when the kids get unwell, I generally believe in ‘keeping it til it gets better’, but watching my baby girl lie listless in my arms stirred up something almost primal in me. I needed to protect her and I needed to do whatever I could to get her better. Of course, this was paired with the realisation that I alone couldn’t fix this and that we were almost entirely reliant on the doctors and nurses. So there I was, anxious, frustrated, frightened and feeling more than a little helpless. Feelings I am sure many of you have experienced in similar situations.
Later that weekend, as things began to calm, I took some time to reflect. Whilst the treatment we were receiving was of course important, the key thing that was making our experience so positive was the kindness; the gentle tones, the sweet smiles directed at my daughter, the hand placed on my shoulder when I was particularly worried and most of all, the fact that those looking after us genuinely cared. I thought about how I had felt when I first arrived at A&E and how determined I was to ensure that my daughter received urgent help. I imagined how I would have felt if the care had been different. What if the kindness hadn’t been there? What if I was dismissed as an over anxious mother? What if somehow they missed something or didn’t give us the right treatment?
I can see how any one of those scenarios could occur and after many years working in the public sector I can also understand how sometimes, there are justifiable reasons for such. As patients and family members we often don’t know what the doctors and nurses are facing. It’s difficult to fully comprehend the overwhelming task they face each and every day with limited resources, conflicting demands and huge, often unpredictable, pressures. We must remember too that they are juggling all of this alongside their own lives, challenges and all. Whilst sitting here on the other side of this experience it is easy for me to apply that logic and understanding, it would however have been very different had any of those things happened when I was actually in that moment, dealing with those big emotions.
image2-2It can be thoroughly unpleasant when someone complains about you. Even more so if you feel that it is unfair or unjustified. We must appreciate however that it is often about perception. The view from every angle is slightly different. We must too remember that nothing occurs in isolation. Just as a complainant may not know what you are facing that day, you may not know their story. Someone once told me that people shout because they feel they are not being listened to. The anger we sometimes see from complainants often stems from fear or frustration. The same emotions that can make us defensive or even dismissive, when we are on the receiving end of that anger. If we approach complaints from a position of empathy and with a genuine desire to learn and improve, we will go a long way towards reaching more positive resolutions.
Until recently, different parts of the public sector had different approaches to dealing with complaints. This meant that patients, service users and customers were facing challenges negotiating the different procedures which, on top of an existing complaint, often escalated their frustration. Staff were also unclear about how to deal with complaints which led to a further variety of approaches. This issue was identified by the Scottish Government a number of years ago and as a result they have been working towards a standardised approach to complaints handling across the public sector in Scotland. The Scottish Public Services Ombudsman (SPSO) has led on this work, already delivering a model Complaints Handling Procedure to local authorities which they implemented in 2013. They are now working with the NHS to help us to implement a very similar procedure from 1 April 2017 and it is a key part of my role to support NHS Dumfries and Galloway with that task.
image3.pngI know my NHS colleagues care deeply about their patients and the experience they have during their time with us. It is however a little more challenging to try to ignite that same passion about legislation, process and statutory timescales. We all know they are crucially important, but colleagues generally just want to get on with the job they are here to do, which is caring for people. It’s my job to help them understand that these changes will make everyone’s lives a little easier. It will ensure we have a clear procedure and a consistent approach to dealing with complaints. It will also ensure that we are offering the best support we can to those that wish to provide us with their feedback. This will help them to tell us their story and will better assist us in our quest to deliver the best possible care to those in need. Something we are all committed to.

You can learn more about the national changes to complaints handling here – http://www.valuingcomplaints.org.uk
To tell us your story about the care you have received, please contact Patient Services by phone on 01387 272 733 by email at dumf-uhb.PatientServices@nhs.net or by visiting the national Patient Opinion website at http://www.patientopinion.org.uk/

Emma Murphy is the Patient Feedback Manager at NHS Dumfries and Galloway.

With occupational therapy you CAN… by Wendy Chambers

wendy-1If I had a penny for each time during my career someone asked me “what is occupational therapy?” I wouldn’t need to be playing the lottery this weekend!

Next week is national occupational therapy week, November 7 – 13th2016, #OTweek16 for those Tweeters out there.

So prior to its launch on Monday I’m offering you the opportunity to have an insight into this lesser understood, enigmatic profession. So pour yourself a contemplative cuppa and have a read.

Occupational therapy is a science degree-based health and social care profession, regulated by the Health Care Professions Council. It is one of the ten allied health professions. You can train to either degree or masters level, at any of three universities across Scotland.

Occupational therapy takes a whole-person approach to both mental and physical health and wellbeing, enabling individuals to achieve their full potential.

We work with children and adults across a variety of settings including health organizations, social care services, housing, education, re-employment schemes, occupational health, prisons, and voluntary organizations or as independent practitioners.

So what does that mean, what do occupational therapists actually do?

Well, as occupational therapists we think about “occupation” as any activity any of us does day to day, which is important, necessary or which we enjoy.

The range of “occupation” is endless. If I use myself as an example some of my daily “occupations” would be putting on my clothes in the morning, reading my emails at work, making a meal for my family, riding my bicycle.

The occupational therapists job is to consider how, if I was the service user, the changes in my mental or physical health are making it difficult for me to be able to do these “occupations”- the things I want or need to do day to day.

They need to understand what’s important to me in my life? What would allow me to stay in control and live my life my way?

wendy-2Occupational therapists are adaptors; maybe that chameleon like ability is why people are often unsure what it is we do?

So for example in order to help me to keep riding my bike after an episode of depression the occupational therapist will problem solve and adapt either:

the activity itself: maybe I should try going out for 10minutes, twice a week, with a close friend who also bikes, somewhere that’s easy to access and doesn’t take long to get there, with a nice coffee shop on the way back

the surrounding environment and tools I use: maybe a tarmac cycle route would be easier, at a quiet time of day, and my bike could do with a service first so it’s working properly (they help me think through planning and organizing that)

me: set SMART goals which I can achieve, to keep me motivated, help me think about what I value about biking and help me understand and make the link between doing an activity I enjoy and feeling better about and improving my mental health

So back to that question again “what do occupational therapists do?”

I guess the bottom line is it ends up looking different each time, as we are all different as people and what’s  an important “occupation” to me may not be important to you.

And we work in so many different settings, with different age groups of people, that that also makes what we “do” look different.

Ultimately it isn’t what the occupational therapist “does” that matters, rather what the person ends up being able to do that’s important.

So for occupational therapy week this year I’ll leave you with this thought,

“With occupational therapy you CAN….”

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Wendy Chambers is Team Lead Occupational Therapist for Mental Health and Learning Disability Service at NHS Dumfries and Galloway

 

Fork Handles!!! by Helen Moores

helen-m-1“The single biggest problem with communication is the illusion that it has taken place” George Bernard Shaw

What is the reading age of the most popular newspaper in Scotland, The Sun?

If you were to categorise it and place it on a shelf where would you put it? 8-10 yrs? 12-14? 14-16 yrs? The answer is 8 years old.

In terms of language level, vocabulary, grammar etc. The Sun is written at the same level as a school reading book for an eight year old child. According to The Literacy Trust the average reading age in Scotland is only 9 years old. This sort of information has massive implications for the way we communicate with our patients, carers, their friends and family.  If we are producing written material or talking in a way that is too technical, medical or wordy we lose, bewilder and alienate our audience whilst thinking we have been clear. It is referred to as health literacy –  the gap between what we as professionals think we have said and what our patients have actually heard or understood or are able to access. It brings to mind the confusion in the classic Two Ronnie’s sketch where a man walks into a hardware shop and asks for Fork Handles and receives 4 candles!

helen-m-2October is World Health Literacy Month and the aim is to raise awareness of this gap in communication. The Health Literacy Place is a website attached to The Knowledge Network and details the Making It Easy action plan to improve Health Literacy here in Scotland. It contains some frightening statistics:

  • 43% of English working age adults will struggle to understand the instructions to calculate a childhood paracetamol dose
  • 26% of people in Scotland have occasional difficulties with day to day reading and numeracy
  • People with lower health literacy have increased rates of emergency admissions, wait until they are sicker before visiting their GP and are less likely to engage with public health programmes eg breast screening and vaccination
  • In general people remember and understand less than half of what we discuss with them

The implications for patient experience, safety and access to services are clear. This is not just a welfare or financial obligation, but a legal one. The Patient Rights (Scotland) Act 2011 states that “people should be communicated with in a way that they can understand and that healthcare staff should make sure that the patient has understood the information given.” Our skill as healthcare professionals is not only to diagnose and treat but to communicate those findings in a culturally appropriate, meaningful and memorable way.

helen-m-3Here in D&G it has never been more timely for us to think about these issues as we plan our own Big Move, thinking about clear signage, systems for patient appointments, e-records etc in our new home. In addition our English neighbours in Cumbria are getting to grips with the Accessible Information Standards. These legal standards were introduced into NHS England on 31st July this year and go one step further in addressing communication needs. They stipulate that a person with a disability, impairment or sensory loss should be provided with information that they can easily read or understand with support. The Standards also state that these needs should be identified and recorded prior to a patient accessing a service.

The good news is that because of the introduction of these standards in England there are lots of resources to help us look at our practice here in Scotland. So where do we start? As a communication specialist, it’s a subject close to my heart.

If you are looking at a service audit or improvements, some handy hints include:

  • to never be without a pen and paper
  • to download a profession specific app or animated sequence for your phone or tablet
  • sit down or be at eye level for all conversations, where possible
  • order a name tag and say..”Hellomynameis…”helen-m-4
  • attend one of the specialist workshops in the Education Centre

but also…….

“Tell me your story…”

Asking this initial interview question allows you time to tune in like a radio to the person’s wavelength. By asking this I can assess fluency, coherence, intelligibility, cognitive ability, word finding skills, language level and most importantly adjust mine accordingly .. but also assess the patient’s accuracy as a historian, their interpretation of events, what they believe the doctor said, if there’s an outstanding or unresolved issue or complaint, their mood and motivation for engaging with therapy, what is important to them, their family, goals, hobbies and start to identify any hooks that I can hang my therapy on to make it personal and meaningful and therefore increase its success. Not bad for one simple question!

 

Perform the SMOG!

The simplified measure of gobbledygook – yes it’s a real thing. Created in 1969, take any piece of written material your service routinely supplies and apply the formula to calculate a reading age. If it’s higher than 9, think again. http://prevention.sph.sc.edu/tools/SMOG.pdf

 

Access The Health Literacy Place

This NES website gives some really great tailored resources for GPs and medics, AHPs and nurses including simple techniques like Teachback, but also online courses, training and templates to re-evaluate and improve your communication personally and within your service. http://www.healthliteracyplace.org.uk/media/1360/health-literacy-month-eflyer-2.pdf

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Chat to a friendly Speech & Language Therapist

But then I would say that! The Royal College has a new position paper and website to support Health Literacy or Inclusive Communication as it’s sometimes known.

And Finally……

…for a chortle and a lighter look at Health Literacy as seen from the perspective of the doctor we all love to hate, click or paste the link below…. If you can’t see it you may need to upgrade your version of Internet Explorer to 11. http://www.youtube.com/watch?v=zG2DVoRP86g

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Happy Friday and happy Health Literacy Month!

#healthlitmonth

Helen Moores is a Specialist Speech and Language Therapist for Adult Service & The IDEAS Team (Interventions for Dementia, Education, Assessment & Support) at NHS D&G

helen-m-7Follow us @SLT_DG

Find us at NHS D&G SLT Adult

 

Health Literacy Month logo and Health Literacy Heroes illustration are reprinted with permission of Helen Osborne, founder of Health Literacy Month

“Going that extra mile” by Sharon Shaw

Patient Centred Care

Being caring and compassionate is an unique talent and sometimes sadly often gets forgotten about and falls by the wayside. We are all human beings and sometimes we all need to take a step back and grasp how valuable our lives are and that of loved ones.

I want to share my story. This is the first time I have written a blog, so please be “patient” with me.

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In November 2015 I started my new job in clinical education. I was excited and yet in a way I wanted to prove to myself and others how valuable education is in this forever changing healthcare environment.

Approximately 3 weeks into my new role, the Respiratory Team contacted me concerning a patient with a complex condition. It was a 59 year old male who had severe emphysema and required an Under Water Sealed Drain (UWSD) to try and reinflate his left lung. The damage was so severe it became evident that the UWSD could not be removed or his lung would continually, spontaneously collapse.

“IT WAS HIS LIFE LINE”.

I walked into the side room in Ward 12 to introduce myself. With hos blue eyes he gazed up at me looking slightly anxious. Giving him a good firm handshake, I smiled and said

“Hello John, my name is Sharon”

I’m a great believer in “non-verbals” as it delivers communication and initially builds upon a trusting relationship. And indeed it did as from then on it had a huge impact.

As my father always said…

“Sharon a good solid handshake goes a long way”.

John was palliative. He had not long retired and to get devastating news about his diagnosis and outcome was so sad. His ultimate wish was to get back home to spend the rest of his short life left with his beloved family.

sharon-2I made a point of seeing John everyday in Dumfries and Galloway Royal Infirmary. It was essential to build up that relationship. During the 2 weeks I delivered education on how to care for a patient with an UWSD. Approximately 30 nurses received education, Kirkcudbright Hospital Staff, District Nurses and Rapid Response Team. As you can imagine there was a lot of anxiety, fear and uncertainty amongst the nurses. This was actually the first patient to get discharged to Kirkcudbright Hospital with a UWSD. John was fully aware of my role and was updated.

The time had come, John was ready for discharge. Understandably so, he was very anxious. I took the decision to actually go in the back of the ambulance with him to Kirkcudbright Hospital. Holding his hand and bantering away we both arrived to our destination. We were pleasantly greeted by the nursing staff. They knew John as he was a local from the town and had received care from them in the past.

His family were so supportive especially his daughter Michelle, whom I have now made a lifelong friend.

John managed to continue life for 7 months in Kirkcudbright Hospital. Unfortunately he did not get his wish to go home but in all fairness the care he received from the hospital staff made his last few months comfortable and to have that precious time with his family. He managed to celebrate his 60th birthday with his family. It was an emotional, uplifting day.

I guess what I’m trying to say folks….

“Going that extra mile” was so successful and beneficial. I would certainly do it all again.

Thanks for taking time to read this.

Sharon Shaw is Clinical Educator for NHS Dumfries and Galloway

 

 

 

Speaking out: A Student’s Perspective by Ren Forteath

I was recently asked to speak at a conference organised by our consultant midwife on the topic of Person Centred Care. She wanted to hear thoughts on the topic of ‘Speaking Out’ from a variety of perspectives and asked me as a midwifery student on placement. I was delighted to be asked to present, perhaps the first indication that speaking out may not be something I find overly daunting! Having a background in amateur dramatics gives me an advantage when it comes to assessed presentations or even leading parentcraft classes when on community placement. The same could not be said of everyone in my class. Even approaching the end of our final year, many of my peers quake with nerves when asked to give a presentation. This fact caused me to consider ‘speaking out’ not only from my point of view, but from that of other students who might be younger and less outgoing than myself. (As a mature student I have quite a few years on some of my class!) The topic encompasses a variety of scenarios, and I tried to think of personal experiences that illustrated my feelings.

On a shift to shift basis we speak to women we care for, other students, midwives and doctors – and sometimes that is no less nerve racking than giving a presentation! Naturally as we progress through our course we become more confident, we gain more knowledge and our comfort zone broadens. But inside there is always a kernel of fear that we’ll say the wrong thing – or not say the right thing. Personally, I’ve had a couple of experiences that spring to mind.

In first year I was with a woman who had written in her birth plan that if things didn’t go as expected and she needed help, she would rather have a kiwi delivery than forceps. I thought no more about it until we reached that point. The reg was called in to do an assisted delivery – and he immediately went for forceps. The woman was fairly out of it on diamorphine and becoming distressed. She couldn’t speak up for herself.  So, I swallowed my fear, took a deep breath and said…’eep’. Then I took another deep breath and said “Doctor, um , she’d really prefer the kiwi, if you don’t mind, please, thank you very much”.  And he did it! She got her kiwi delivery and she was so happy. And I was absolutely on top of this world! It was so exhilarating. I had been an advocate for my woman. I had spoken up to a doctor – and he hadn’t bitten my head off! And then second year happened.

I was on shift and we heard an emergency buzzer, so we all ran to room 7: and it was a shoulder dystocia skills drill. Well, really, what were we expecting? There was only one woman in labour that day and she was in room 3! So one person took charge and started working through the HELPERR mnemonic and I thought “hey, I remember this, I know this stuff”. Then the consultant walked in, made a quick assessment of the situation and said “O.K. with a little fundal pressure, I think we can get this baby delivered.” Everyone else just looked at each other and I was thinking “that’s not right  – I know that’s not right – it’s suprapubic pressure.” And then someone suggested doing exactly that but the consultant said again “Come on now,  a bit of fundal pressure! Please, will someone put their hand on the fundus?” And I thought “it’s not right, is it?” And as if of its own accord, my hand started to move. Well, his voice was just so hypnotically consultanty. Then my mentor shot me such a daggers glance that, seriously, if looks could kill, that midwife would be in prison today! My hand shot back down, but not before at least two other people had seen it. So that sparked a useful discussion on listening to your inner voice and always speaking up, diplomatically, if your knowledge of evidence based practice tells you something is wrong. It also sparked a debate on whether it’s appropriate to use ‘making the student feel like a prize turnip’ as a teaching technique. And I wished the floor would open up and swallow me whole.

And now I’m in third year. There is light at the end of the tunnel and I’m beginning to believe it is not an oncoming train. I still have a lot to learn but I’m really starting to feel like part of the team. I suggest things and people listen. I coach women through fear and panic to relief and joy. I hold my own.

A large part of how easy or difficult it is to speak out is the people you are surrounded by. In my clinical area we have great teams, both in hospital and on the community. My classmates who have been here on rural placement always say how much they enjoy it; the working environment, the attitude, the team. People are encouraging, patient, willing to listen and keen to teach. They are inclusive and welcoming. I have rarely been berated for starting to do something the way I was shown at Uni rather than the way the midwife I was working with that day would normally do it. Not never, unfortunately, but rarely and never by a mentor.

Having my student placements there has made my own experience a hugely positive one and has equipped me to find my voice and to know how and when to use it. I know that many in my class feel the same way about their mentors in their own areas. Speaking up and speaking out are still not always easy…. but we’re learning, and as we complete our degree programmes and step out into the wards as shiny new midwives, we will find the strength to speak for our women, and for ourselves.

  • Trust your learning – if your evidence base tells you it isn’t right, say something (even to a consultant)
  • You are her advocate – if she can’t speak for herself, it’s your job to speak for her
  • Be diplomatic – just because you need to say it, that doesn’t mean you have to upset anyone
  • Find your voice – you can have a positive impact by saying the right thing at the right time

Ren Forteath is a Student Midwife