Saturday, 29 December 2012

Compassion in nursing

There have been a number of distressing news stories recently that have called into question public trust in nursing as a caring and compassionate profession. Partly of course this is just one of the Tories' more despicable tactics in their quest to undermine this nation's faith in its National Health Service, and a tactic that some of the tabloids seem more than happy to assist with. It appears that the sight of a large state-run enterprise doing something as important as protecting the nation's health with such success and such overwhelming public support brings out the inherently destructive nastiness of the neo-cons this side of the Atlantic too.

No doubt there is some basis in truth for such stories of medical staff, including nurses, treating vulnerable patients with neither compassion nor dignity. In any organisation as vast as the NHS there are bound to be some whose motivations are twisted, or whom bitterness, despair and the intolerable stresses of their work have transformed into monsters. And given the nature of their work, if even tiny numbers of nurses are or become monsters, then the power they have over the safety, comfort and indeed life of patients at their most vulnerable is frightening.

However for these stories to gain the currency they have there has, I believe, to be more to it than either Tory tabloid vindictiveness or the despicable behaviour of a tiny minority. Is there then something about what nursing has become that allows the general public to believe that nurses are less compassionate, less caring, than they used to be?

I have recently spent a considerable amount of time in hospitals with my wife, culminating in a few days in the Hyper-Acute Stroke Unit where she died. Sitting at her bedside I had a great deal of time to study the nurses and doctors who cared for her and, while I was immensely impressed with the way they did so, I began also to think about how their role has changed over recent years.

The most obvious change is in the very high degree of professionalism, medical expertise and efficiency required of nurses in today's hospitals. Even something as simple as changing a dressing has become a meticulously thought through and elaborately choreographed procedure that ensures that at no point will anything that is to come into contact with the patient's skin touch anything that is not sterile. Maintaining fluid balance is no longer simply a question of periodically checking up whether the patient has passed urine. In patients on close monitoring every millilitre of fluid in or out is recorded and if a patient has gone more than a specified time without passing urine then a nurse will use a small single-purpose ultrasound scanner to measure the contents of their bladder, considering catheterisation if that quantity exceeds a certain preset threshold. Every aspect of the patient's condition is recorded and cross-checked, with doctors paying as much attention to the nursing notes as to their own, and even something as simple as putting up a bag of saline bound around with procedures and safety checks to ensure that no patient receives the wrong interventions.

And of course everything, but everything, is entered into a variety of databases, both physical and electronic. Nurses have to spend a considerable proportion of their time entering, cross-checking and retrieving data. Of course there are those in the swivel-eyed nether reaches of the Tory party who would point to that very fact as prima facie evidence of the schlerotically bureaucratic nature of the NHS, but the nurses can hardly be blamed for their need to record everything. And neither in fact should the NHS itself. Not only do meticulous records help prevent the sort of appalling accidents in treatment that make for one branch of the anti-NHS tabloid stories (War Hero Has Wrong Leg Amputated!), they are also the only sure protection against the rapacious hordes of injury lawyers who haunt the daytime TV schedules. Even in the midst of the appalling horror of witnessing my wife's sudden death I could not help but notice the nervousness of the medical staff on the ward. Was I going to be the one who blighted all of their futures with a long-drawn-out and bitter battle to establish fault? And the meticulous recording of every detail of treatment is the only protection against malicious accusations of malpractice.

Yet even these additional pressures on nurses today are not, I believe, the central issue in their changing relationship with the patients they treat, and those patients' relatives and friends. Busy as they were, the nurses caring for my wife did so with good humour, compassion and genuine humanity. Whilst the procedures they carried out were such as at one time might have been more associated with doctors they carried them out in such a way that my wife was accorded respect, dignity and even affection. And yet, as I watched them, I began to see some of the ways in which the transformation of nursing from a vocation to a highly-skilled profession could be seen by some as inimical with the image of the compassionate, caring nurse.

Perhaps the clearest example of what I am talking about is the issue of post-thrombolytic monitoring. Thrombolysis (from the Greek- 'thrombos' = a clot and 'lysis' = destruction) is what is popularly known as clot-busting. If caught early enough, many of the effects of an ischemic stroke can be lessened by administering thrombolytic drugs, which dissolve every blood clot in the body, including the one which is depriving part of the brain of its blood supply. This is of course a procedure with considerable risk, not least of which is what is called a hemorrhagic transformation, where the blood clot on the brain is replaced by a brain bleed. To guard against this, nurses have to monitor any thrombolysed patient very closely for 24 hours. And this monitoring is not simply a question of blood pressure, temperature and the rest. The nurses actually have to carry out neurological tests every hour ("Raise your right arm for me. And your left. Now make a fist. Push my arm away. Now pull it towards you..." and on, and on, as the exhausted patient stares beseechingly into their eyes, willing them to stop, to let them sleep.)

This monitoring is clearly absolutely vital and a major factor in the successful treatment of strokes that not long ago would have resulted in death or very severe disability. Yet, on the face of it at least, such monitoring is the very opposite of compassionate. Everyone, especially nurses on a Hyper-Acute Stroke Unit, knows that stroke causes exhaustion. Twice I have been with my wife in the aftermath of a stroke and I can tell you that exhaustion is too pallid and commonplace a term to describe what she went through. In the old days, I am sure, compassionate nurses would see a stroke patient so washed-out, so drained with the simple task of taking a sip of water that they would let them sleep for a while. "I'll come back later," they would have said. "She looks exhausted." And now what do they do? At 3 a.m they come to that same exhausted patient's bed, call to them incessantly until the patient drags themselves from the depths of their desperately sought-for sleep and make them do what my wife called those bloody stupid neurological tests. And then again at 4 a.m. And 5...

Surely that can't be compassionate, a part us must inevitably feel as we witness such nursing. Don't you see how tired she is? Just leave her alone, why can't you?

I didn't say it of course, because they were doing exactly the right thing. What sort of compassion would allow a nurse to leave a patient sleeping while unnoticed in the depths of their brain a hemorrhagic transformation was spreading its dark tide of destruction? The old-fashioned "compassionate" style of nursing that engaged with the patient rather than their medical condition might feel more human and soft-focussed and personal, but I know which I would prefer if it was me who was acutely ill and in imminent danger.

And so in fact I have emerged from this terrible experience with a new-found admiration for the functioning of the NHS at the sharp end, and for the professionalism, expertise and (yes) compassion of so many nurses. As the ones in closest contact with the patients dependent on their care it cannot be easy for nurses to carry out procedures that they know to be painful, uncomfortable, or even distressing to a patient at their most frightened and vulnerable. And yet they do so, efficiently  professionally and, in the most part, with real humanity because at the root the nursing profession is, more than ever, solidly founded on a basis of true compassion.

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