The four pillars

the four pillars

So again its been a while. I’ve neglected my writing. In to the latter stages of the course now and the pressure is, well its got a bit much really. I’m quite proud of making it this far without resorting to tears in my consultants office. There is no shame in crying I just find it annoying as it tends to catch me out at inopportune moments, like in the middle of a shift. The reasons behind my tears were that the many plates that you are expected to spin were starting to waver and I was not sure if could or even wanted to keep this whole act going.

My first words on entering the office were preparatory 

‘I’m going to cry’

Door shuts, I sit down and say 

‘I can’t do this anymore.’

I actually decided to myself that weekend that I was going to quit. The course was just making me miserable. I had gone to Scotland and it was beautiful being outdoors in wide open spaces but I just felt rubbish and guilty that I wasn’t studying and ensuring I was going to be the best ACP ever. If I’m I totally honest with myself its not that the course is too hard it is the fact I have no idea where I fit in the ACP role and if I even like what it appears to promote. The more people talk about these four pillars the more I feel like this metaphorical construct has been created to ensure people can talk their way into highly paid jobs and flit around the country promoting themselves for being great under the guise of conquering an imaginary concrete post.

That was very angry sounding wasn’t it and I fully grasp the point of them however…I have been a bit angry and disillusioned to say the least.

I came into advanced practice for the exact same reason I came into nursing. Simplistic as it maybe. I want to make people feel better. I don’t feel the need to demonstrate which pillar I am fulfilling in doing that. The problem is I’m not there yet I have a lot more hoops to jump before I am afforded the luxury of being able to do this job the way I want to.  

I had a conversation with one of my academic supervisors recently. They had asked how I was feeling, where I was at on the Fischer model (remember that from my previous post). I explained I was feeing ready to give it all up. I seem to, as always, miss the point of what is expected of me. What they said next made it a little clearer. 

They explained whilst I am an adult, being at university is unfortunately an extension of school and there are specific ways of doing things and that is just how it is. 

This didn’t really help with my disillusionment but it did make things a bit clearer on the academic front.

I just was not prepared for the guilt and isolation that comes with this course. It’s been almost 2 years of just work minimal respite and what now feels like compete isolation from my normal life. People say it’ll be worth it in the end. I’m still not overly convinced it will be. There hasn’t been ups and down for me during this course its mainly been a downward spiral and it has been a constant struggle to hold on (dramatic analogy but feels apt).

I feel guilty about everything. Making time for family and friends is hard. Even time spent with them my thoughts are distracted with things I should be reading, researching or writing. It is true it is a time you discover who your real friends are. Thankfully I have a small but well formed support network and I have even found a new friend to help along the way. I wouldn’t have got this far without them. 

After saying the words ‘I can’t do this anymore.’ I gave myself a reality check. I realised I needed to take some time for myself. I decided to do Inktober where you draw every day, there’s a prompt sheet so I don’t even have to think what to draw which is helpful. It has been a welcome distraction even if my drawings at the start were somewhat embarrassing, but it wasn’t about that. For me it is the process of learning to draw and accept the permanency of ink.   

I can do this. 12ish more weeks. Main aim to continue to be resilient AF!

First stop clinical reasoning exam wish me luck. 

MJ

Gone

I haven’t written for a long time. The main reason being I have been so incredibly sad. She died on a Saturday and despite the world’s relentless spinning, I needed time before I could move with it. Things still aren’t the same, you were with me for as long as you could be. Now you’re somewhere else that I cant be. I wish this wasn’t so.

That’s all I have to say about that.

What have I been up to other than being sad? I took a holiday, the sun shone and I swam in the sea. It was good for soul.

I’ve now entered the last 6 months of my advanced practice training and despite the threats of this last effort being equally as hard as the first it doesn’t compare. The first 6 months of training were unnecessarily hideous. In the first couple of weeks you are shown a graph depicting how you will feel throughout your journey into advanced practice. Fisher’s model of transition (2002). It basically depicts a journey that has ups and downs.

I was never quite sure why no one ever intervenes and tries to prevent the fear, anger, guilt and depression phase. I asked this in university once … surprisingly the lecturer couldn’t give me an answer.

If this graph is my journey I don’t know where I am really. Last week I would say I was at the ‘did I really do that?’ phase, after removing a fish hook from someone’s finger. This week on a grey Monday morning I’m feeling indifferent toward the week ahead but there doesn’t seem to be a phase for that.

I am looking forward to this last 6 months. I do not doubt it will be tough but the end is near, nearer than it was 1 year ago. I appreciate this has not been the most interesting of reads but a friend gave me strict instruction to write again. Write anything just to start again for the longer you leave it the harder it will be. He was right. This has been difficult. I will try again soon.

MJ

Human

‘Will your system be all right

When you dream of home tonight

There is no message we’re receiving

Let me know, is your heart still beating’

Talk about resilience and stress management came into focus a few years ago and I remember having to look up what it meant. The ability to bounce back, recover quickly and not shy away from challenging situations. Am I resilient? Yes… Well sometimes. Sometimes I am not.

I recently attended a conference. One of the speakers, an ED consultant, gave a talk on resilience giving a personal account of how things became too much. Her talk was one of the highlights of the day and she promoted the importance of kindness and respect for each other and not forgetting to look after yourself.

Resilience seems to be one of those hot topics of conversation alongside incivility through out healthcare. Twitter is full of various trusts displaying a posters and messages reminding staff to be kind and take a moment to pause, consolidate and reflect. It’s lovely to see these little reminders and it is lovely to hear people talking about being kind, but l find myself asking why are people needing to be told to be kind? Has incivility and arrogance ever been acceptable? Why has it been allowed to exist amongst a work force dedicated to providing care and compassion to others? Why are caring individuals so apparently uncaring towards each other and how does sticking a poster onto a wall change anything?

Incivility is a nice fluffy term for rude and offensive. Over the recent weeks there seems to have been a huge drive towards being civil, being kind to your colleagues. In my years in the NHS I have met some of the rudest, egotistical beings. These people do not use fluffy terms when they speak. They get angry and sarcastic and never apologise. They will engage in some virtue signalling hashtag and conveniently omit any memory of their incivility. A poster will not change these people, a hashtag will not atone for their behaviours. It is a truth universally acknowledged that some people are just massive dicks.

The ED is often described as being a place full of ‘strong personalities’ a fluffy way of saying confident, difficult, inconsiderate and/or obnoxious. I accept and openly admit to work in the ED environment it is essential to have a degree of assertiveness and cognitive ability to manage highly stressful situations. In times of high level stress assertive communication can be mistaken for rudeness. However people that work in the ED, and have done for many years, do so because they want to. They adapt to working in said environment and generally have developed their own coping strategies of how not to be a complete asshole towards others. ED staff like any speciality learn to survive in that specific environment. The ED is varied, relentless and unforgiving. Could it be that the longer you stay in this hostile environment the more hostile you become, and this is how we have found ourselves having to be reminded to be kind?

The answer quite simple is no. The problem with the increased lack of resilience and incivility comes from the increasing pressures put on a service that has been systematically driven into the ground by our government. Our services stretched so thinly they are starting to tear. It is the care and compassion of NHS staff that is holding it together. The current drive of promoting mental well being of staff within the NHS is great to raise awareness and encourage people to talk about these things but a poster on a wall isn’t going to fix those already broken and burnt out. Everyone has a limit. We are human.

Some humans are kind and considerate, some humans are not. As socialised adults we learn acceptable behaviours and should all have enough self awareness that making somebody feel small, insignificant or stupid is not acceptable. No amount of hashtags, posters or mugs of kindness can help with that.

Nobody is perfect, we all have those days where we could have adopted a kinder approach. The important thing is that if you notice your colleague is acting unkind remember they are only human.

Ask are you ok?

They might not be.

MJ

Change

Drama school gave me three years to experience what it was like to create, to be free. They encouraged us to push the boundaries of the arts to the extreme. Now I will be clear, I did not always enjoy this pushing of boundaries … I can clearly remember one lecture we were shown a piece by blood letting artist Franko B called Performance. He walked a catwalk naked and bleeding. It was a piece about the human form. His art made me cry. I was upset and decided this man was obviously ill and being exploited. My tutor disagreed he saw it as complete brilliance, art in its rawest form. Truly pushing boundaries, this is art. Having experienced a little more life than my 18 year old self I view Franko B differently these days. To be honest I hadn’t really thought about him much until Monday.

Year 2 third lecture of project management. My goal for this year is simply to survive, head down do what I’m told and just to be normal. No cartoons and keep my creative flare well and truly packed away. Third lecture they give us play doh!

This was our introduction into project management, we were to work in teams and create an outpatient space for patients to use on receiving bad news. We had to present our project and provide a visual aid with a model made out of lego and play doh. Whilst my team busied themselves making furniture I made a grim reaper and a lotus flower. The idea behind this was symbolic, patients entered a space that facilitated detachment from fear and encouraged clarity of thought. When I explained this to my tutor she and some of my peers laughed dismissively. I didn’t understand, had I yet again missed the point of the exercise?

Prior to this we had been given a presentation about project management, SMART ideas and such. The lecturer spoke of a man called Mr De Bono the ‘father of lateral thinking.’

She spoke highly of this man and how lateral thinking enables a person to be creative by wearing one of six coloured hats. Each hat encourages the thinker to evaluate an idea in a different way. De Bono describes creativity as ‘a skill that can be learned just like mathematics.’ I disagreed how can creative thought grow and flourish whilst bound to a structured process, is this not just a rebranding of vertical thinking. If I’m honest I don’t think I ever think of my thoughts as horizontal or vertical but I understand the concept of ordered thought which I assume is the point. I agree with S.B Kaufman who writes of the need for structure and practicality when actualising an idea. However when structure and practicality are applied at the very start of the creative process it immediately enchains the thinker, stifling their thoughts as they are bombarded with the negative practicalities of reality.

The beginnings of creativity are never structured, ideas emerge from the most obscure sources, the most enjoyable part of the creative process is taking an idea to the extreme of its possibility, fully immersing yourself in it, allowing the constraints of reality to disappear, your ideas are limitless. To fully explore an idea the thinker must be able to envisage the emotive aspects of what they are trying to achieve. The use of artistic mediums such as lego and play doh enable the thinker to visualise these concepts. That is creativity, that is art and art is part of everything. It is not a skill to be learned it is inherent in all of us. Society has given us rules, social norms and values to adhere to that actively discourage creative thought. Create something that is original and creative but within the realms of acceptable. Is that what lateral thinking is? Is this the best way forward in quality improvement, stand on the shoulders of those before us, continue to think like they do, do what they do?

I grow tired of working within a system that on the surface appears to promote change and encourage new ideas, yet seems completely averse to creative thought. I can now see what my art tutor saw in Franko B it wasn’t about whether you liked Franko B’s performance it was about accepting that it was valid. Just because it was different does not mean that it was wrong. It is that message that I want to take forward. In reality there is a definite need for structure and maybe wearing multicoloured hats helps you do that. However be wary of the application of structure to creative thought. Be inspired by the smallest things and let your imagination feed that thought, allow it to grow without the constrains of reality. Once you have found your eureka moment then work out how to make it a reality. Understand others may not accept your way of thinking but this does not make your idea or approach any less valid, you may just have to be a little creative with your delivery.

MJ

http://www.imagination-institute.org/

http://www.franko-b.com/I_Miss_You.html

https://www.edwddebono.com/

Just

Disclaimer this piece is purposely written devoid of political thought.

Just

Synonyms

Simply

Only

Not more than

At best

At most

Why as nurses do we refer to ourselves as ‘just’ a nurse when we are responsible for so much?

I came across this question whilst scrolling through twitter, its thread filled with comments about demanding respect and deserving higher pay. The statement ‘we are responsible for so’ much left me feeling uneasy. Nurses do carry a great deal of responsibility but they do not act alone they are part of a vast network of care givers that provide treatment and rehabilitation to those in need.

I often use the phrase ‘I’m just a nurse’ or ‘I’m just doing my job’ but this is not attached with negative connotations of assumed inferiority. Whilst I understand this avenue of perception, I cannot help but wonder if there is too much emphasis on this incessant need for all we do to be recognised and measured.

I fear we run a risk of losing the key attributes of modesty and humility which are so vital in any care giving role. They are basic human qualities that are often neglected in these times of overwhelming positivity and pursuits of greatness. Why is there a constant demand for attention or praise? Being ‘just’ isn’t always a negative it is sometimes what is needed.

One reply to this question was that we are not ‘just’ anything we are part of a team ‘just’ getting on with it. I second this. There are times when it doesn’t matter how clever you are, what role you have or what advanced skills you possess, it is recognising when to take a step back. Simply show kindness and compassion to a person in need. A simple act, achieved by ‘just’ being human.

I had the privilege of meeting a man at end of his life. He arrived alone. In the space of a not more than a few hours he was told he had cancer with extensive metastatic spread, it could not be cured. At most he had a few days but at best he had only hours. Five to be precise. I stood there feeling completely useless not knowing what to do. He looked at me and said

‘I’m scared.’

I tried to come up with something profound or meaningful to say.

‘You’ll be ok.’ of course he’s not going to be ok you idiot, my inner me groaned.

He smiled and said ‘hakuna matata … I’m ok.’

He thanked me for my humanity and said he was grateful for all I had done for him.

I just got him a hospital bed to lay on.

I just gave him pain relief.

I just gave him some water.

I just sat at his side.

I felt as though these simple acts were not enough I wanted to do more but there was nothing more. In spite of the marvellous things we are capable of as part of a team or as individuals he didn’t need a super nurse, an amazing doctor or fantastic ACP he just needed someone. Not trainee ACP me, not ED Sister me, just fellow human being me.

We spoke a little about life and religion. He said he probably should have been a better Muslim seeing as though he was about to meet his lord.

I said

‘I don’t think he would be that bothered, as long as you tried.’

‘I did.’ he said.

We discussed the existence of multiple omnipotent beings and came to the conclusion there was mostly likely not more than one.

He held my hand for a while and we simply sat two people ‘just’ waiting.

MJ

Happy New Year

2018 the year I lost a part of myself both literally and metaphorically. From a trainee ACP perspective I can honestly say I am leaving this year feeling so much more confident than I was 12 months ago. For those of you who are just starting your journey and the immense amount of work weighs heavy on your mind know that it does get better. Don’t get me wrong I have spent the Christmas period lay awake at night plagued by waves of anxiety, a bit like the spirits that visited Scrooge on Christmas Eve although they all seem to be as menacing as the ghost of Christmases yet to come rather than the friendlier two. I worry about work I’ve done, need to finish and need to start. I worry about my decisions were they right, why do the other trainees seem so much further ahead than me? The list is endless and exceedingly tedious. Then last night I watched The Greatest Showman and I had a bit of a revalation … you will have to bear with me on this but I promise it’ll make sense in the end.

It would seem I am behind the times as I had never seen The Greatest Showman, a film that by all accounts a former drama queen should love. I had been assured by my theatrical friends that this was the film for me and I would love it. Love it I did not. Hugh Jackman will forever be Wolverine and to see my beloved Wolverine skipping around singing about a business deal with a guy from High School Musical was all a bit much for me to take in. I struggled through it, mainly out of fear that if I didn’t make it to the end I’d be ousted from my friendship group. I was pleasantly surprised and also relieved with the ending. I had made it to the end which was an achievement but also the films parting message brought forth an unexpected period of reflection about my journey into Advanced Practice so far.

“The noblest art is that of making people happy” P.T Barnum

I left drama school to go into nursing, the interview for nursing school was an arduous process of having to explain why I wanted to give up dreams of the west end for a career in care. My answer was always the same … I just wanted to make people happy. The interviewer looked at me disapprovingly over his half rimmed glasses. He gave a wry reply of ‘never had any one say that before.’ He went on to remark that if I wanted to make people happy I would better suited to continue my pursuit of a career in the arts. I managed to blunder my way through the rest of the interview process and as the country was desperate for nurses they let me in. I had to wait six months before they would let me on the course, they said it would give me time to see if nursing was really for me, maybe they had hoped I’d get tired of waiting and give up on the idea. I didn’t and here I am almost 1 year into my masters and hoping to be nearly finished by the end of 2019.

Making people happy has always been my drive in nursing, there is no better sense of job satisfaction than when a patient or relative smiles and says thank you.

These thank you’s maybe sparse, but come from a place of pure sincerity and are given on the patient or relative reaching a point of contentment that even on their darkest day they have experienced a level of care that has made their experience in the ED a little brighter. As a nurse I could write about numerous encounters in which I was able to bring happiness to people who needed it. As a trainee ACP I had forgotten how important it is to look out for these moments.

One of my fondest memories of a thank you was as a nurse newly qualified in the NICU (neonatal intensive care) it came in the form of a smile on a new father’s face when I passed him is newborn baby for the first time. His wife was in adult intensive care following complications at birth and the baby had breathing difficulties. What was meant to be such a happy time had been overtaken with sorrow and concern. By giving him his baby to hold, the worries disappeared and he was happy.

The ED is more challenging environment to make people happy. I’ll always remember *Albert, the 75 year old red sepsis standby that despite our best efforts, it was just his time. It was an odd situation, he was fully conscious and aware of everything he was apart of the decision making process to withdraw treatment and had accepted this was the end. His end was as dignified as it could be in the middle of a busy ED, surrounded by family and friends. They sang songs and told stories of days gone by. I asked Albert if I could get him anything, he was hungry so off to the kitchen I went… the cupboards were bare. I went back to tell him we didn’t have anything but I had an orange and mildly squashed piece of lemon cake in my bag. Turned out lemon cake was his favourite and his eyes lit up and he said that would be perfect. In that moment eating a squashed piece of homemade lemon drizzle he was happy and that brought comfort to those he was leaving behind.

In the all consuming vortex that is MSc Advanced Practice I had forgotten the importance of these moments. They are subtle and small but it is important you take time to appreciate every one. Reflecting on my first year as a trainee ACP I have had quite a few ‘thank yous’ handshakes and hugs. I have no way of evidencing them but remembering these moments gives me reassurance that I am making a positive impact on my patient’s life. So despite my worries and concerns, thanks to the message of The Greatest Showman I have allowed myself a brief respite from anxiety and concern. I have gained knowledge, learnt new skills that have given me the ability to continue with the art of making people happy. Knowing this I am content.

Merry everything and happy always

MJ xoxo

*names changed obviously!

Old and small

Assessing a person’s level of confusion can be quite a tricky task. It is surprising how ‘normal’ a very confused patient can be, yes there are scoring tools but even those can be misleading. I am one of those people that despite a few years in the ED, tend to believe everything the patient tells me, especially if they are old and small.

Doris was 94, about 4ft 11 and weighed about 6 stone. She had curly white cauliflower hair, dark twinkling eyes and bilateral hearing aids that whistled loudly. As she lay compliantly on the trolley I completed my assessment. She had given me a full history and a plausible reason for being out in the street in her dressing gown, she had been putting the bins out. Given her small stature I thought this a bit odd but during my neuro exam I had discovered she was also inordinately strong, I asked her to squeeze my finger and actually thought she was never going to let go. She then proceeded to proudly kick her legs up with such force it was only by chance she didn’t kick me in the face. It was only the mention of Nurse Sam and his dark tan that had alerted my suspicion to her mental capacity.

Sam had recently returned from 3 months in Gambia. He had been all over the world but had manage to avoid being one of those annoying traveller types. We’ve all met them. The ones who find any excuse to regale tales of how they ‘saved the Africans.’

Doris had asked me who was the ‘shifty looking Arab’ who kept asking her about, who she lives with and does she have any pets or pressure sores. I had thought it was a bit of a strange comment. As I was weighing up whether this was simply generational racism or confusion I noticed a tuft of white curls float past the workstation. I got up to investigate and I realised Doris was making her way along the ambulance corridor at an alarming rate.

“Doris… DORIS … Where are you going?????”

Doris had stealthily manoeuvred passed numerous staff and was making her way slowly but surely to the exit. Despite her advancing years she appeared to have the vigour of a child on their way to find Santa. As Doris made her way passed the triage nurse I stopped in awe of her athleticism although the potential consequence of Doris’s adventure along the ambulance corridor became all to real as the Nurse in Charge appeared at my side.

Sharon was one of those salt of the earth types and had worked in the ED longer than anyone else. She knew everything and ran a tight ship. She was not impressed, she looked sternly at the computer and then at me before letting out a long sigh.

‘She’s not had a falls assessment! This is going to end in a datix!’ she muttered disapprovingly.

I was just relieved I had been fortunate enough to have spotted the white perm strolling past the workstation. If she hadn’t of been my patient or if I hadn’t noticed the flapping of her hospital gown revealing her vest and pants I wouldn’t of stopped her. She moved with such intent and looked like she knew where she was going.

Slowly but surely Doris continued to totter down the corridor towards the sliding doors of freedom. I was at a loss of what to do next, my shouts had fallen silent on her whistling hearing aids. I called to one of the paramedics coming out of the kitchen door.

‘Stop her will you.’

Mike was carrying two cups of tea and cradling a packet of bourbon biscuits in his mouth. To be fair what happened next was his only option. Mike assessed the situation stuck his foot out and down Doris fell. Doris didn’t move, she just lay there. Spread eagled on the floor Tena pants displayed for the world to see. I rushed to her side glaring at Mike who shrugged his shoulders and nonchalantly wandered over to the ambulance reception and placed down his cups of tea, before checking she was ok.

I knelt down next to Doris, checking her over and internally praying to every god I could think of that she hadn’t broken something. Doris looked at me, white hair stood on end, bright eyes starring into mine…

‘What are we doing on the floor dear? We haven’t got time for sitting around…The Chinese are coming!’

And it was at this point I realised Doris has significantly less marbles than I had initially thought. From that day on I vowed to stop believing everything patients told me no matter how old or how small they were.

MJ

XOXO