Nursing staff were the dominant group in terms of physical presence on the wards. The doctors undertook formal and informal ward rounds reviewing patients under their care. Therapy staff had contacted with patients requiring physiotherapy or occupational therapy input.
The orthopaedic trauma ward was extremely busy, patient call buzzers were constantly activated, the ward telephone rang constantly. It was observed that patient contact tended to be task orientated, such as attending to general hygiene needs. Patients on the trauma ward had been admitted via the accident and emergency department having sustained a traumatic injury that required surgery or conservative treatment. The majority of patients were high dependency calling for intense physical and emotional support from all staff pre and post operatively. Anxiety and distress was evident in many of the patients as a result of their traumatic experiences, with several elderly patients having cognitive impairment/dementia due to co-morbidities such as Alzheimer’s’ disease. The ward was a frenzy of activity as a result of a continual and intense workload. On the elective orthopaedic ward, the atmosphere was one of relative calm and silence. Patients were admitted to the ward for planned surgery or treatment, due to the high volume of scheduled theatre cases each day the ward was busy. Health care professional contact was task orientated although the majority of patients were self-caring. Emotional support was mainly part of any educational or counselling required and was clearly evident in the observed contacts. At the time of the observed sessions there were no patients with cognitive impairment on this ward.
Staff on both wards dealt with interruptions as they endeavoured to care for patients during the observed sessions. These included general telephone enquiries, enquiries from other hospital personnel entering the ward, and visitors. The most noticeable interruption for the senior nursing staff was the number of times they were called away from patient care to discuss bed occupancy figures, one nurse was called to answer the same enquiry three times, from various hospital personnel. The highest number of observed interruptions per hour per session was 12 on the trauma ward and 7 on the elective ward.
Page | 174
The amount of time each health care professional spent with their patients depended upon the task being performed, for nursing staff contact could be as little as five minutes in order to take a blood pressure or a temperature and as much as one hour to perform a bed bath. Medical staff spent between five and thirty minutes on average with their patients and therapy staff between twenty minutes and one hour.
Orthopaedic trauma ward observations
Six caring interactions were observed during pre-arranged sessions on the orthopaedic trauma ward. Two early shifts, one late shift and one night shift were worked. The interactions facilitated the emergence of a myriad of caring behaviours demonstrated by each of the health care professionals observed. The caring behaviours were demonstrated via physical or verbal interactions and in most cases by a combination of the two. It was noted that as the dependency of the patients was high on this ward staff were constantly late for breaks or late going off duty. Some took their break in the ward managers’ office, as they were unable to leave the ward. The observations from this ward are presented as six vignettes; findings will be discussed after each.
6.5.1. Observation 1
It had been a busy evening on the ward but by 20.00 hours things had started to settle although the staff were still busy with patient care. The phone rings at the nurses’ station, it rings for some time before it is answered by nurse 4 a staff nurse of eight years.
Nurse 4. “We could do with someone here of an evening just to answer this thing,” pointing at the telephone.
She was in charge of the ward on this particular shift; she appeared tired and somewhat flustered.
She picks up the telephone and after talking for a couple of minutes she puts it down.
She shrugs her shoulders.
“We have another admission coming, male, fractured ankle; they’re bringing him up from accident and emergency in about 10 minutes
Page | 175
(referring to patient1). That doesn’t give me much time to get things sorted, still have the gents in there to do.”
She gestures her head towards a side cubicle.
“I think I’ll put him in there, I don’t think he’d thank me for putting him in with the other men.”
This was a reference to bay C which was full of elderly confused male patients.
She starts to prepare the bed and goes off down the ward to get equipment. Within a matter of minutes two porters wheel patient 1 onto the ward. As Jenny comes back down the ward she notices the trolley and porters. “Christ, they don’t give you a minute do they?”
She turns to the porters, “I thought they said ten minutes?”
One of the porters shrugs his shoulders, “Where do you want him?” “In the cubicle,” nurse 4 replies.
A nurse from the accident and emergency department rushes onto the ward.
“Sorry I’m late, forgot the prescription chart.” She proceeds to give handover to nurse 4.
The handover takes place in the doorway of the cubicle, and then the staff nurse from the accident unit bids a hurried farewell to the patient and rushes off the ward.
The time was 20.30 hours and the night staff were beginning to arrive on the ward.
“It’s going to be a late one tonight,” Nurse 4 shouts to one of the staff as they walk onto the ward.
“I’ll be with you as soon as I can, just had an admission from accident and emergency, do me a favour, make a cup of tea for this man.”
Nurse 4 starts to attend to the patient; she introduces herself and then immediately gives an apology.
Page | 176
“Look I’m sorry, it’s been really busy this evening, just give me a minute and I’ll be back with you.”
She asks the patient what he prefers to be called. “Right, I’ll be back in a minute.
Nurse 4 rushes off to empty a catheter bag for a patient in the adjoining bay then after five minutes she returns to the cubicle.
“Sorry about that, right, now let’s get you sorted”
Nurse 4 then spends time admitting patient 1 to the ward, using a dynamap (a machine for monitoring blood pressure and pulse).
She takes the readings talking to her patient. “Are you in any pain?”
Patient 1 shakes his head.
Nurse 4: “Oh, I see they gave you some morphine in the department, well if you start to feel anything err pain just let me know, ok?”
Patient 1: “Yes, I will.”
Nurse 4 rummages in the patients’ emergency notes; she pulls out a piece of paper and writes down the readings from the dynamap machine.
She then looks up at her patient.
Nurse 4: “We can give you something to eat and drink, they’re making you a cup of tea, and do you fancy anything to eat? I’m afraid it’s only sandwiches, no hot meals at this time of night.”
Patient 1 replies that a cup of tea is fine and that he is not hungry. He is clearly distressed.
As she finishes her tasks nurse 4 notices how upset patient1 is, she stops what she is doing and spends some time chatting with him offering reassurance and support; her voice is softly spoken and she encourages patient 1 to tell her what is distressing him.
At one point during the conversation she puts her hand on his for a few moments before withdrawing it.
Page | 177
Nurse 4: “Do you want me to give anyone a call for you, perhaps your wife?
Patient 1: “No I’m fine I’ll ring my wife in the morning if I can?” Nurse 4: “Of course anything you want.”
“Ah, here’s your cup of tea, that’ll make you feel better.” She laughs and patient 1 gives a little smile.
“I’ll be back in a moment, just got to let the night staff know what’s happening, here’s your call bell, just press that if you need anything, we need to get that ankle elevated so I won’t be long, I’ll get a hand and we’ll put that leg up on a frame.”
Twenty minutes pass while nurse 4 hands over care to the night staff, once handover is finished the night staff tell her to go home.
“I’ll just give you a hand elevating his ankle.”
Nurse 4 promptly picks up the frame and enters the cubicle, the night staff nurse follows.
“Right, we need to put your leg up on this frame; it’ll help reduce the swelling and pain.” She explains to patient 1.
Patient 1 nods. The task is completed quickly.
“Right are you going now?” Asks the night staff nurse.
Nurse 4 replies that she has not finished her documentation and she’ll do that before she goes home.
She approaches patient 1, putting her hand on his arm.
Nurse 4 introduces Patient 1 to the night staff nurse and asks if there is anything else he needs before she goes off duty.
Patient 1 shakes his head and thanks her for her kindness.
The time is now 22.10 hours, nurse 4 goes off duty forty minutes after the end of her shift.
Page | 178
Summary of findings and analysis for observation 1.
It was evident from the observed session that the nurse (nurse 4) was particular busy with emergency admissions which was compounded by an existing cohort of high dependency patients under her care on the observed shift. Despite her heavy workload she still demonstrated a number of caring behaviours during her interactions with patient 1. Critical analysis of this vignette reveals evidence of all five caring caratives although each one differs as to the number of times it is observed by the researcher during the caring observation. The analysis is represented in the following table.
Page | 179
Table 6.6: Analysis of caring interactions during observation 1.
Carative category Carative intervention Observed behaviour Physical and non-verbal interaction Vignette Line number 1.Respectful deference 2. Assurance of human presence 3. Positive connectedness 4. Professional knowledge and skill
Developing and sustaining a helping- trusting authentic caring relationship. Practice loving- kindness and equanimity within context of caring consciousness Provision of supportive, protective and/or corrective mental, physical, sociocultural and spiritual environment. Systematic use of scientific problem- solving method for decision making. Promotion of interpersonal
teaching-learning.
Attentively listens and allows patient to express feelings. Introduces self to patient.
Is sensitive to the patient’s needs. Being there for the patient.
Asks patient preferred name
Demonstrates respect for patient and is interested in the patient as more than a health problem. Is humane in approach, shows warmth, consideration and kindness. Recognizes the vulnerability of the patient Assists in making the patient comfortable. Verbally assess patient in relation to symptom control e.g. pain Gives an explanation as to the need for treatment in advance of the intervention. Touches patient’s hand Touches patient’s arm Smiles 38 38 21 20,29,35,38, 40,45,54. 27,38,54. 23 26,28,39. 53 29,31,35,38,39, 42,44,45,53,54. 38 29,31,49. 29,31. 49.
Page | 180 5. Attentiveness to the Other’s experience. Assistance with gratification of human needs. Monitors patient condition closely. Takes account of basic needs e.g. diet and fluids. Is responsive to the patient’s needs. Provides comfort. 27. 20,35,43. 31,38,40,45 31,38,45,49,54.
This table illustrates caring observed by category, intervention, behaviour and physical/verbal interaction, the vignette line number is provided for ease of reference.
The dominant caring carative was assurance of human presence with a total of 15 caring behaviours observed in this category. Demonstrating a humane warm approach, being kind and considerate were the most observed behaviours arising from both verbal and non-verbal interactions. Caring behaviours from the caring category respectful deference were the second most frequently observed (14) and focused upon the ability of the health care professional to be sensitive to the needs of the patient.
Attentiveness to the other’s experience was the third most frequently occurring caring behaviour (13), this alluded to providing comfort and responding to the needs of the patient.
The fourth was positive connectedness where behaviours such as assessing the patient in relation to control of symptoms such as pain relief were observed (5) and finally professional knowledge and skill where explanation of treatment in relation to injury was provided to the patient (1).
Physical and non-verbal interaction included smiling and touch which was observed on two occasions.
Page | 181
6.5.2. Observation 2
09.00 hours on the trauma ward, by the nurse’s station the daily multi-professional meeting is taking place. The ward is busy; lots of activity, three patient call bells are ringing. Ward telephones are constantly ringing, noisy environment particularly on the main ward. One of the senior nurses is giving the daily report on each patient to the ward based physiotherapists and occupational therapists. Occupational therapist 1, is working with physiotherapist 1 this morning to assess patient 9, a 61 year old man who had sustained an injury to his knee whilst on holiday in England. Patient 9 is an ex-patriot who now lives in the Philippines and is classed as a bariatric or obese patient. Occupational therapist 1 and physiotherapist 1 have had difficulty communicating with patient 9 on previous visits because they say that he does not listen to their advice and wants to do things his way which are not possible. The assessment needs to be undertaken in order to facilitate his travel back to the Philippines, comply with airline safety regulation because of his poor mobility and ultimately ensure that he is safe once he reaches home.
Occupational therapist 1 and physiotherapist 1 walk into bay D towards patient 9 who is situated in the corner bed reading a newspaper.
Patient 9 looks up.
Patient 9: “Look out here’s trouble.” He points to the staff approaching his bed.
Occupational therapist 1: “Behave yourself, what are you like?” Occupational therapist 1 wiggles her finger at patient 9 and smiles.
Occupational therapist 1: “Right then, we’re going to have another go at getting you sorted out this morning so that we can get you home.”
The researcher says hello to patient 9.
Patient 9: “whose side are you on, theirs or mine?” Researcher: “I’m on the side of what’s best for you.” Patient 9 laughs and shakes his head.
Occupational therapist and physiotherapist 1 want to see how patient 9 manages to transfer independently from the bed to his wheelchair.
Page | 182
Patient 9 is not happy.
Patient 9 “I can manage so you can go away; I don’t want to be bothered.” Occupational therapist 1 and physiotherapist1 both discuss the importance of
the assessment as they will need to know how he will cope once he returns home; Physiotherapist 1 says that the health system is not as good in the Philippines so patient 9 will need to have equipment to take home.
Patient 9 is unhappy.
Patient 9: “What’s all the fuss about?” Patient 9 waves his hand.
Patient 9: “I’ll manage despite you lot.”
He looks down and starts to shuffle his newspaper.
Patient 9: “You lot weren’t around to help last time I hurt myself and I managed then so why are you bothering now?”
Occupational therapist 1 and physiotherapist 1 try to reason with patient 9, they talk with him calmly.
Physiotherapist 1: “We need to make sure you’re safe at home”, we’re trying to help you get home, we care about how you are going to manage, that’s why we’re here now, spending time with you so that we can do that.”
Patient 9 raises his voice, he starts to get up from his bed, then flops back down, he sighs heavily.
Patient 9: “I manage fine at home, my wife will help me, if I say I can cope, I can cope” (raises his voice).
Occupational 1 tries to explain again the need for assessment but patient 9 interrupts then starts swearing at occupational therapist 1.
Patient 9 “Bloody interfering lot.” Physiotherapist 1 keeps quiet.
Patient 9: “You’re all obstructive and you’re not helping me to get home.” After several minutes of arguing patient 9 complies with occupational