Nursing a grievance=


THE Oncology Ward in University College Hospital, Galway, is a miserably unappealing place. If I fall ill, dear God, let it not be here. In fact, dear God, if I fall ill, let it not be anywhere in UCHG.

This is no reflection on the hospital's medical or nursing care which ranks with the best in the country. But environmental gloom and decay pervade the building. No one denies it. On top of that, the 60 year old hospital is no longer capable of supporting its catchment area.

The other day, its Casualty department hit the headlines once again after 22 patients had been nursed overnight on trolleys. Strange compromises are made to accommodate the overflow - like the time a patient was moved from a cancer ward to the postnatal area - and nursing administration is under constant pressure to free beds.

"I've worked in Baghdad and the Middle East but I never saw anything like it," said a ward sister about one frenetic night when patients with oxygen masks and kidney stones were nursed on trolleys, an old man with chest pains lay on a stretcher between two ambulance attendants, and nurses fought to keep out the icy draught that swept through Casualty every time another member of the public came through the door.

Nurses carry the can for the practical inadequacies: for the beds that are "as old as Florence Nightingale"; for the bed table that has lost a wheel; for the absence of bedside sockets; for the lack of oxygen/suction facilities over the beds; for the ward design which means hefting beds closer to the nurses' station when a patient needs extra vigilance; even for the way the food comes down, unplated, and professional nurses stand at food trolleys like chef waitresses, waiting to serve up.

And yet, back in the Oncology Ward, the struggle to restore health and hope is as stout and relentless as in the shiniest new hospital. It has been painted a shade of dusty pink to brighten it up a bit, but to the unfamiliar visitor it is a heart turning dose of reality. The very air seems suffused with an ineffable sadness. Each bed appears to represent an ashen faced struggle to fix some shattered dream: a 19 year old fighting chemotherapy side effects; a young mother coming to terms with a horrifying prognosis; an elderly man who has beaten the odds before but may lose his last battle any time today. How does a nurse report in here day after day? Do they survive by suspending imagination and empathy? Do they just get used to its Not in this ward.

The nature and treatment of the illnesses means that patients can be around for as long as three months at a time. During the physical and emotional rollercoaster ride of first the tests and then the treatment side effects, a bond is often forged between nurse and patient as intense as any in the outside world.

"When I'm in here," said a young mother of three, "those nurses are my family." Under the calm, clear philosophy of Sister Marie Dempsey, this small tight team of strong women is there from beginning to end. They often see death in these wards. In the past few weeks, they have lost three patients. Tonight they will lose another. Two of them are just back from a patient's funeral in Limerick. A nurse mentions that a colleague has, herself, lost a parent recently. "I'd still be a bit concerned about her. But you get three days off if your father or mother dies and then you're coming back into more death and dying."

FOR anyone seeking a clear distinction between the working conditions of a Grade Four civil servant and a nurse, this is probably as good an illustration as any.

In Australia, there is a time out provision which they call "blue days". In St Ann's Surgical ward, Sister Doreen Garvey knows well that given the general staff situation, such a perk would be impractical. But even within the hospital, there is little space of any kind - emotional or physical. "Even for those times when you have a clash with a patient," she says, "you don't have the space. You're like an elastic band. I have no rest room here for the girls. The nurses' station is like a family room. Hospitals are not friendly to the carers. You haven't the time to take time out, but there's nowhere to take it anyway."

There is nowhere on the ward to have coffee, no place to interview patients. When distraught relatives need to talk and plan for an uncertain future, the corridor is the only place. Lunch, served up by Campbell Catering, is in a barn like room which offers no enticement to sit and chat. Anyway, there isn't time. They get only half an hour for lunch and 15 minutes for the morning break.

At midday, in small rooms containing makeshift tables, a few chairs and a drugs cupboard, nurses meet for the "handover" to the next shift. This entails a detailed report on each patient, encompassing diagnosis and prescript ions, social circumstances, prognosis, current state of mind. By now, the bathing, the drug rounds, the blood taking, the blood pressure and temperature checks and the bed making will have yielded up not just fragrant and well monitored patients but a good picture of their state of mind.

The senior nurses handing over punctuate their reports with such references: "He's in good form today"; "she's a bit down - she didn't want to get out of bed"; "he's sitting up like Cock Robin - I asked him how he was and he told me he hadn't asked himself yet!". There are sighs of dismay when the new shift hears of a readmission. They remember her from before - "She's a nice lady - but her new prognosis is poor."

This emphasis on psychological well being is a revelation. Those apparently casual nurse-patient chats clearly have a serious purpose. An elderly woman confesses that she is afraid to return to her lonely house, but equally dreads the thought of a nursing home. A stroke victim has been living with his niece until this calamity; but she has four young children and is already caring for his ailing wife. Another is anxious to maintain his independence but his medical condition rules this out; his only next of kin is a nephew and he distrusts him. There is the elderly woman admitted with hyperthermia whose memory is faulty; a young man on chemotherapy depressed about the loss of his hair; a family which may be in need of alcohol counselling ... These nurses cannot walk away from the so called "social problems".

The Patients' Charter states that no patient has to go home and some relatives take this literally. All over the hospital nurses note that when first admitted, elderly patients will have family flocking and fussing around them; come discharge time, often enough they have melted away like the snow.

What happens then? Well, in Dublin, you pick up the phone and pass it on to a social worker. In Galway, ward sisters can often he found ringing around nursing homes, liaising with the public health nurse and the community health officer to find a safe haven for such patients.

BACK in the Oncology ward, Sister Dempsey dons her plastic bib and gloves to help turn a man whose resistance to infection is dangerously low. He is susceptible to septic shock, but in his condition the signs can be difficult to gauge. So they are constantly on the alert for paleness, clamminess, a drop in blood pressure, a rapid pulse rate . . . They move him with infinite care, chatting to him, apologising for the discomfort.

Because it is worn lightly, the nurses' responsibility for patients' lives is rarely noted. Consultants do their rounds, carry on to other wards and private practices and are well rewarded for their labours. Junior doctors, as everyone knows, work fiendishly long hours, rushing from one call to another, one ward to the next. But the nurse is the one on the spot. She (or sometimes, he) is often the one to use her experience and expertise to make the first judgment call, to detect the first signs of deterioration, call the "crash" team and initiate emergency treatment.

Often on the evening drive home to her baby boy, Marie Dempsey finds it hard to banish the mental video of the day's events, running over and over. "If you had a busy evening and somebody had a cardiac arrest, you'll probably be thinking - did you do everything you could for them? Were you fast enough? Did you document everything? Did the arrest team get there quickly?" All day, she has managed that 33 bed ward, kept nurses and junior doctors on the straight and narrow, taken responsibility for their every move; at night, she knows she is still in charge. For that, she takes home around £1,100 a month and that includes the "premium" for working a weekend.

Because of the hugely increased patient turnover in hospitals, in patients tend to be more sick and have a higher dependency than before. Add to this an increasing awareness by patients of their rights and the rush to litigation for even minor mishaps. (A Dublin nurse recalls one patient who busied himself taking copious notes every time a hospital employee went near him.) Quietly, almost imperceptibly, these additional responsibilities have fallen on nurses.

No nurse I talked to had any objection to the Patients Charter; indeed, Sisters Dempsey and Garvey have a vision of patients as partners in their own care, and revolutionary notions of patient autonomy - with nurses as helpers, planners and facilitators. But the charter, say many nurses, has left patients in a far better position than their carers: "It's left us open to abuse, criticism and stress without any restructuring.

A nurse with a grain of ambition now has to embark on management and communications courses. Thus, from Director of Nursing (formerly Matron) down to first year staff nurse, the profession has been engaged in a long, lonely and personally expensive revolution in further education. The importance of this to the profession cannot be over estimated.

Offered a hypothetical magic wand by The Irish Times to help the profession, Josephine Bartley, Beaumont's Director of Nursing, didn't hesitate; she would use it to find time and financial assistance for further education for her nurses. Meanwhile, they make do. Some are part funded by the health boards and get some study leave. Others carry on alone, rising sometimes at 5 a.m. to drive to Dublin for a day's lectures, returning to the west the same evening.

Senior nurses claim that after such a course, they will often know more about the specialty than junior doctors. But at the end of it, unless the nurse is hired to apply the knowledge in that specialised area, there is no financial recognition of her studies, however useful it may turn out to be in her general nursing care. They seem to be engaged in a relentless struggle: with emotional and physical stress, with mortgages and childcare arrangements, with a society which purports to value them above rubies but treats them in practice like uniformed skivvies.

IT is all of a piece with the man (a teacher, apparently) who wrote a letter to a newspaper, bilious about the notion that nurses would dare to class themselves as professionals. His letter adorns noticeboards in nurses' stations throughout the State; he should pray for a forgiving sort of nurse should he ever need hospital treatment.

Nurses are no angels. They are fallible beings working under a system riven with staff shortages, "temporary" nursing colleagues who have little continuity, and a chronic shortage of money and support services. An elderly man recently left waiting, disconsolate, in a Dublin hospital on discharge day, could have been spared the distress if just one of the four messages left with nurses had been conveyed to him. Later it emerged that just two nurses and a sister had charge of 22 patients. Scapegoats for the system or thoughtless women?

They are beginning to speak out at last. Some are even prepared to identify themselves. What they want is better working conditions and a fair rate for the job. (The current offer is an extra £150 a year for staff nurses with 15 years' service). The question is - what took them so long?

They number 26,000, a vast army, mustered under a hierarchy with strong roots in religion and the military. Traditionally, they have been female, compliant and subservient, working to the ethos of nuns whose position within the church echoed that of women in the home - "essential but sub ordinate".

"The nursing environment", wrote Jean Clarke, a UCD lecturer in nursing studies, in a recent issue of Irish Nursing, "socialises us into perceiving ourselves as powerless, at times unworthy, and a belief that `we do not deserve to have what we truly desire'." In other words, blame not the nurses but the structural environment of nursing. At last, it seems, nurses are beginning to unravel the plot.

Back in the corridor, Sister Marie Dempsey pauses to chat to a distressed relative. The woman is angry and bewildered that the patient's immediate family seems casual about visiting. The Sister listens sympathetically and offers her a cup of tea. Elsewhere in another corridor, another relative aggressively buttonholes a nurse: "Has my father not been seen yet?"