Tag: nursing in England

Life is Never a Straight Line

January 20, 2023 / Tamara

Like walking down an unsteady path and having to curl your toes to steady yourself, the last six months have been a bit turbulent. Some may call it a midlife crisis, but I kind of went through that when I packaged up my family and moved to England. This period has been more of a career reevaluation. A turbulent one, but one in which I think I have come out ahead. Time will only tell. As any emergency room nurse in recent times will tell you, we are overworked and our light has been dimmed. Many of us have left the field. I did too, going into the field of anesthetics, then doing another a bit of a U turn.

But first,

Before I share that tale with you, I would like to share a conversation I had with a trusted friend years ago that is still fresh on my mind. I was talking with her on my commute home. Catching up after a tough day in the emergency department (ED), venting to her about not getting my break until 8 hours into my shift. It had been an especially grueling day. And now I had a scratchy throat and felt like I was getting ill. She said to me point blank, “Well maybe you love your job, but it doesn’t love you back.”

She was referring to the fact my job was not conducive to self-care. Regularly, I went six-plus hours without a meal and held my pee for ages, always putting my patients needs ahead of my own. By the end of most shifts, I was hangry, on the verge of a urinary tract infection, and exhausted. Talking to her, I got defensive. Didn’t she understand that I put my needs aside to care for others? To be there for them at the most vulnerable point. Didn’t she know how altruistic I was? Didn’t she get what it was to have a career, not a job, one that you’re passionate about, that you put your entire soul into. Why didn’t she see it?

Maybe, I couldn’t see how much of myself, both physically and emotionally, I was giving, and how it was breaking me. And she did see it.

During COVID being an ED nurse also ment having marks on your face from the FFP3 masks

Fast forward, ten years later

I am living in England, working in a smaller community hospital and thanks to better management, I do get my breaks. The work is still hard. I am on my feet for hours. My system is still on high alert waiting for the next emergency. And as research has shown, persistent surges of adrenaline is damaging on blood vessels and puts you at an elevated risk of heart attacks or stroke. Not to mention the toll of the night rotation every other week that is hard on this old mother hen. Even though it is rewarding being an emergency room nurse it comes at a cost, the cost of my own health.

I decided that I was ready for a new challenge, a career change, and it led me to anaesthetic nursing. It is a different field here than back home in the USA. In England, you are the assistant to the anesthesiologist, his helping hands, versus an independent practitioner like in the USA. (My next post will be about the lessons learned whilst an anesthetic nurse.)

A new way of life

The change in field also altered my hours and my way of working. I could be home for dinner most nights and on weekends. I not only had my lunch breaks, but additional tea breaks as well. It was easier on my body, and no more adrenaline surges. Then, as I settled into this new area of nursing, walking the sterile halls of theatres (operating rooms), I learned that the clinical educator in the emergency department was leaving.

Before leaving the emergency department, having been so recently in their shoes, I had taken on teaching and giving guidance to junior nurses and recently-arrived international nurses. I found myself falling asleep at night thinking about how to describe a second-degree heart block to one of the newbies. The language of medicine lives with in me.I realized I get a thrill being able to share that language with others. Thus, the U-turn: I took a chance and applied for the position.

A Chance

I was short listed and granted an interview, my first ever management interview. That is the moment I started leading a double life. By day I worked as a new anesthetic nurse, and by night, I prepared for the interview. It consisted of creating and giving a presentation on the topic of “linking clinical education to recruitment and retention.” Two weeks later, days before the interview. I found myself walking the English coastline, practicing my presentation, titled: “Empowerment Through Knowledge: A Culture of Education”.

the coastline I walked as I recited my presentation

The day arrived, my heart was racing, my breathing exercises did little to relieve the dripping sweat from my armpits, but I felt I did well. The interviewing team, unable to decide that day, requested a day to think about it, uncommon in England. Over the following twenty-four hours, I realize the immensity of what I had just signed up for. If I got it, it was going to be a challenging position, and a difficult one to leave behind at work, as any schoolteacher well knows. Was I again choosing a job that I loved too much?

The Quandary

In the middle of the night following the interview, sitting in an empty staff breakroom waiting for an emergency worthy of an operation. I put down the book A Promised Land by Barack Obama and let my mind wander. Thinking about a possible future as the clinical educator for the department I heard the echo of Obamas words: the importance of inspiring others, is a worthy cause. Was it my fortune to guide other nurses on their journey. Or was I about to take a position that would consume me? I live and breathe the nuances of being a nurse, but can I leave it at work? Will this impede the precious moments I have left in son’s childhood?

As I crawled into morning, I was still unsure of which future I wanted. Truth be told, at this point in time, it was out my hands. But those 24 hours gave me the opportunity to reflect on the decision I was making, and the life I was choosing. Was it time I choose something for my whole self, not just for part of me.

The day before this, my wise husband asked, “will you ever be happy?” It made me chuckle and think, when will I be satisfied? Back in the States, I had strived to be a critical care transport nurse, then a pediatric emergency nurse, then the move to England, and into the operating theatre, and now clinical educator. What am I looking for? What is it I was striving for? I needed to remind myself to stop, and soak in the moment after a goal has been reached, instead of looking for the next goal.

I did not get the job.

A sense of relief laced with disappointment seeped in. I heard the universe telling me to focus on life in England, on home, my family, so I jumped fully into anesthetic nursing, no longer having to lead a double life.

The role expanded my perspective as a nurse, but it removed some of my best skills, IV starts (cannulation) for example, or thinking on my feet during an unexpected critical situation. But I had the space to let my mind wander, and the time and energy to learn new things. I found myself being thrilled during the first hours of an operations, but then I would just get on my phone and let time slip through my fingers. I became very good at Wordle and discovered Quordle.

With spring in full bloom, we headed on holiday. While soaking in the sun on the Costa del Sol, I got a call from Mobile Medics International, an NGO, to go to Romania and help with the refugee crisis stemming from the war in Ukraine. Still in training for anesthetics, I easily slipped out for a week and went to help.

On one of the days there, walking the streets of Galați, looking up at the tall cement buildings and the blue sky, my phone buzz. I had an email. It was from a fellow ED nurse at Winchester, letting me know the clinical educator assistant job (a part time, fifteen hours a week) had been posted. There I was in another country, helping to treat minor ailments, but using my skills. And teaching the local volunteers first aid as they prepared to go into Ukraine. Was the universe giving me a nudge? I put aside my fears of rejection and as soon as I got back, applied. And I got the job.

Facing the Fear

So, after five months of anesthetics training me, with only weeks to go until I was practicing on my own as an anesthetic nurse, that I put in my notice. The conversation with my manager was one that caused a tight knot in the pit of my stomach. I knew I was jumping back into the madness of the emergency department, working there part of the time, and the rest as the clinical educator. Was it the right choice?

That day, as I cycled away from the hospital, there was a group of monks chanting, a calming hum overtaking the traffic noise. It felt right. I was taking a risk in the right direction.

Learning to care for myself amidst chaos

So, I was back in the craziness of the emergency department. I felt a flutter in my chest but one of joy. A comfort to be back in a familiar environment. A feeling that any ED nurse knows after they have left the ED only to be drawn back. My first day back in the ED I was thrown right into the trenches working in one the busiest areas. The pressures could have easily overwhelmed me, but I kept telling myself to breath. And my focus for the day was to keep everyone alive. I might not complete the hourly observations/vital signs right on time, but I would provide level of care that goes beyond the numbers.

These two positions gave me balance. The two twelve-hour shifts as a staff nurse giving me an accurate pulse of the department. Then the two eight-hour shifts as the assistant to the clinical educator where I could I provide hands-on teaching and create education material for the department.

The Unexpected

Then the day came when the clinical educator and emergency department matron (director) pulled me into their office. The matron was going on maternity leave for a year, (the standard in the UK) and her position was being filled by the clinical educator which left a vacancy. One they asked if I would fill.

My current balance suited me, even though I rushed around to provide the education I wanted in the 15-hour weekly limit. I was not sure how I would handle teaching full time. Should I take another chance?? My mind replayed all the chances I had already taken, from going to the visa department when the country was shut down to moving to England. The hard part was done.This was another chance that had to be taken. The new goal was not to lose myself in the chaos of my work.

I applied, I interviewed, and I got the job.

How do we learn to give it our all without losing ourselves?

There are a couple components to the question. First, to remember to care for yourself, otherwise you will not have the energy to care for other. Second, learning to be uncomfortable. Whether it be caring for patients or working with colleagues, we need to empathize and be uncomfortable with them, without losing ourselves. As Brene Brown famously states: to be able to connect with other we first must be brave enough to get in touch with our emotion. I also like to remember that a moment of uneasiness for us, it just that a moment. A moment for us to connect, but for the other person it is a permanent mark. So, by learning about ourselves, our emotions, we can hold on tighter and not lose ourselves.

A fellow nurse once told me a story of an elder woman whose husband had just passed. She was a young nurse then, and it had hit her hard. She was crying. The woman told her “Darling it was my husband, it is my loss. You have your job to do. It is not your grief to carry.”

Back to the beginning.

I started the year looking for a change in my career, something that brought more balance to my life, and in a roundabout way, it found me.

I am breaking in this new position, learning to be uncomfortable with unfamiliar tasks and duties. Advocating for staff to be given time off to attend courses in a department that has no funding. And in my spare time I am learning about male catheterization the English way so I can teach it to the department.

All with an effort to leave it behind at work and not bring it home. I have been pulled into nursing again, and pulled away from writing.

I am about to turn forty-two, and a goal in life, a purpose, it is to leave something behind beyond myself. To cause a ripple that surpasses my existence. Education fulfills that purpose. I am still figuring out the nuances of my teaching style but now it is a full-time job versus two shifts a week. I am learning as much as I am teaching, growing humbling.

Straight lines in life do not allow you to see things from different angles. I do not know what this year will bring, but I am learning to care for myself a bit better, challenging myself in a new role, and learning to let go of work on my ride home each evening.

My new normal

September 22, 2021 / Tamara

I used to look out into a spacious waiting room with an enclosed Chihuly art piece tucked in the corner. At times it was bursting with ill children waiting to be seen, all under my supervision. I would run through my head, recalibrating who was sickest, who was in need of analgesia, or who needed a new set of vital signs. I had the independence to administer medication without a second check since it was all computerized. My old world, one which is fading now. The current waiting room, or closet thing to it here, is a skinny white tent with a queue of patients waiting to be seen. At times the line extends into the parking lot.

I have learned (or learnt) to be a nurse in a new capacity. Fellow international nurses say you take a step down from the autonomy you held back home, but I think of it more as a side step. I am no longer wearing a stethoscope every day, nor do I know the results of all my patients, but in exchange I get to talk to them and learn their stories. By taking that side step I am able to look around and observe the difference in health care

Is care better?

In the Emergency Department (A&E) care is more efficient. Is efficiency better? The fact is eighty percent of patients get their disposition in less than four hours. Almost every patient with an acute complaint (ESI 3 or higher) will get an IV (cannula), labs (bloods) including a venous blood gas, EKG (ECG), and a COVID swab on arrival. An hour later with lab results in hand (the doctor’s not mine) you know whether the chest pain needs a cardiology consult, additional work up and admission.

A venous gas result is ready in less than two minutes and very helpful in diagnosing a septic patient or a patient with diabetes ketoacidosis

Most patients admission is to the Emergency Medical Assessment Unit EMAU. This is where further evaluation is completed. Such as CT scans, heart rate control, or potassium replacement. EMAU provides care up to a progressive care unit (PCU) level. If the work up extends past a 24 hour period the patient will then move to a specialized ward. General practitioner (GP aka PCP) also directly admit to EMAU bypassing the A&E all together.

A typical patient in our A&E is a little old man curled with age and his tweed cap faithfully at his side. The one in my head arrived via ambulance with “long lie” due to being “off legs.” In other words he was found on the floor after an extended period of time by his carer. due to leg weakness. He took the time to read my name badge and it struck a chord in me. Reminding me of the value of being called by your name. He received the work up previously mentioned but even with his complex history everything came back normal. In these situations we arrange an In Reach evaluation.

The In Reach Team

In Reach is team at the hospital that evaluates the patient and their needs to be able to stay at home. The assessment includes checking mobility, family support, and overall safety of living conditions. The team provides the patient with appropriate assistive devices, arranges for district nurse visits or meals on wheels.

No More Pelvic Exams

Diagnostic studies must be justified. Even a head computed tomography (CT) scan must be accompanied by altered level of conscience or blunt head trauma with persistent vomiting. Elevated inflammatory markers is the only way to land an abdominal ultrasound. And even at that, it will be scheduled for the following morning, not in the A&E. If you suspect acute appendicitis the patient goes directly to the operating room/theatres.

A young female with upper abdominal pain will get the work up mentioned and sent home to follow up with their GP. More weight is placed on the physical assessment versus jumping to a CT scan. Children that present with abdominal pain first get an assessment, then urine analysis, possibly blood work but an ultrasound will only be done if deemed necessary after blood results. We are more likely to schedule it as an outpatient or to monitor the child overnight. I am torn to which is better, at times things are missed when you skip the scan or an ultrasound but then again you do not always need it. Things here are not better or worse, just different.

A female with lower abdominal pain or a pregnancy complaint will get stabilized then sent to the OBGYN ward in a neighbouring building. A young pregnant woman with heavy bleeding presented via triage the other day. After I obtained her vital signs I paged (bleeped) the GYN doctor and sent her directly to the OBGYN ward. Pelvic exams are not done in the A&E! At first sending a patient to another building just because they required pelvic exam seemed foreign. Now, it just is.

What about Sexually Transmitted Diseases?

No emergency treatment required therefore patients get directed to a specialized clinic. The sexual health clinic offers contraception, free condoms, testing for sexually transmitted infections including HIV.

Stroke Team

The hospital, and most hospitals in the NHS, have a dedicated stroke team. The team consists of a doctor and health practitioner. The health practitioners are trained in National Institutes of Health Stroke Scale (NIHSS) assessment. The NIHSS is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit. In addition to placing IVs, determining if the patient will require thrombolytic intervention (“the clot buster drug”) and transport the patient to CT. The doctor does the formal admission and will be present if thrombolytics are administered. A stroke patient will get their evaluation by the stroke team and admitted within a couple of hours. The A&E nurse will assist with paper work, medication administration, but no need to transport the patient for CT or do the NIHSS assessment.

Minor Complaints

When I started, I was blown away when an Emergency Nurse Practitioner (ENP) guided a smartly dressed woman directly into one of their exam rooms. The chief complaint was a foreign object in her ear. Turns out it was a piece of her hearing aid. I never really saw the patient, only glance at her in passing, she bypassed triage. The ENP took the chart, took the foreign object out, did one quick set of vital signs and discharge her. The staff nurses do not get congested with these patients. Other patients that will get seen by the ENP directly are limb injuries such as a sprained ankle or a simple laceration.

Minor complaints (ESI 4/5) get seen by ENPs, a different scope of practice than back home. For example, an ENP in England would not just evaluate a simple urinary tract infection. But being previous A&E nurses, they do everything from start to finish. The triage, wound care, x-ray ordering and reading, plastering (applying a cast) all without any help from an ER tech or another nurse. ENPs are very independent and hold their own.

Seeing things from a different side

Learning to see things under a different light reminded me of Begonia, a stern retired teacher we stayed with during our travels in Spain. She could not brush off her years of teaching and was always sharing her wisdom. During our final night, I was complaining about the world’s agonies and she grabbed my hand and held it up. She was looking at the back side with the cracks on my skin and I was looking at my palm. Then she said “we are both looking at your hand, right? But we are looking at two very different things because of where we sit.”

When I arrived I saw thing from the American view, now I see them from the other side.

A Sundry of Difference
-We do not administer narcotics instead we give paracetamol IV. I have given morphine less than a dozen times in the last year.
-Patient to nurse ratios are 5:1, pediatrics 8:1, and ICU level patients 3:2
-A medical cold blue is an incoming sick patient not a cardiac or respiratory arrest. Those area announced as a cardiac/respiratory arrest.
-No ambulance phone just a screen, we only get a phone call if the patient requires a resuscitation bed.

How has all this changed me as a nurse?

I have had to recalibrate how I see myself and emergency care. It is no longer about trying to find the mystery diagnosis or a reason for admission. It is now about figuring out if the patient needs immediate treatment or what support they may need from the community to lead a healthy life at home.

Back home I am just another nurse, but here due to the vast difference in training I am a source of knowledge. I have learned to carry that knowledge carefully and use it as a mean to elevate those around me. A personal goal is to teach the newly arrived foreign nurses of the intrinsic difference in England. I have learned to Trust myself a little more and not be afraid to have voice, embracing my American heritage. I now introduce myself as the American nurse working for the NHS.

Exhausted but Learning

December 29, 2020 / Tamara

The week before the holidays I completed my supernumerary (orientation) period and I wrapped up my induction to the National Health Service (NHS) Foundation Trust. The foundation Trust, an important detail in the words, is a different type of NHS organization with a stronger local influence and some may say is leading to the privatization of the NHS.

During the holiday week I was christened as a solo nurse. I held my head above water but my arms were flapping the entire time. I have an impending doom feeling at work. Worried constantly I will do something wrong. Miss an important part of the process, a piece to the puzzle I cannot see right now. Be misunderstood due to the language difference. Or give confusing information to a patient for the same reason.

The puzzle of the commode chair going up the stairs

Communication

The other day I asked a patient who had fallen off their bicycle and scraped his legs an instinctive phrase, one I have recited many times, which could have turned out to be a very awkward moment. I handed him a gown and asked him to “get undress and please make sure to take off your pants”

“Pardon me?” he responded with shocked unsure look.

“Please get undressed including your pants,” and that is when I heard myself. “Oh, your trousers I mean, you can keep your pants on.” My explanation of having just arrived from the US did not soften the mood. The phrases I once recited without thought I now must alter.

Medications

As I mentioned before, medications are in locked cupboards that require a code to unlock. Inside the locked cupboard is another locked box with the controlled. The keys for the box and cupboards are held by the charge nurse but get passed around throughout the day depending on who needs them.

You prepare your own medication. I already got my first nick from an ampoule (yes that is the correct spelling or at least in the UK) bottle. Everything seems to be in ampoule bottles and I am still figuring out how to finesse them. We do not have a pharmacist to double check or prepare our medications. This week alone I prepared an insulin infusion, multiple antibiotics, and the trickiest was acetylcysteine for paracetamol (Tylenol/acetaminophen) overdose. The acetylcysteine had to be calculated based on weight. Then drawn up from 5 ampoules, pushed into an intravenous bag filled with glucose. But first I had to create the 200ml intravenous bag since there were only 250ml bag. Talk about thinking things through.

Another revelation is narcotics are given out less frequently. I have not given out more than 10mg of Morphine in the last month, and that was divided between two patients; the first with a sternum fracture after blunt chest trauma and the other for a kidney stone. The first choice for analgesic is paracetamol 1 gram intravenous, which works wonders but is not used in the US due to high markup. How is society different when narcotics are given out more conservatively? I hope to investigate further…

Critical Thinking

I was told by a fellow US nurse working in the UK that once I got here all my critical thinking skills would be pushed aside. “Nurses are more tasked oriented”…. that’s what she said. Like everything this holds some truth, but I feel I do more critical thinking here than back home. Here you do not have a computer or an electronic medical record system (EPIC) to guide your triage. You have a bare box for your chief complaint to be described in less than 500 characters. Your knowledge base must be solid to differentiate a cardiac chest pain versus pulmonary emboli. Choosing those 500 characters carefully, remembering the PQRST of pain assessment. And you triage based on Manchester Triage System (MTS), which I am still learning, but also on your clinical knowledge. And as many fellow nurses know, not every chest pain is Emergency Severity Index (ESI) level 2.

Even with newness and overwhelming feelings I am still happy to be practicing nursing in the UK. Colleagues often ask me why I came to the UK which is not a straight forward answer but one I will elaborate on another occasion. But one of the key reasons is to care for the patient without the worry about the cost to them. Healthcare here is a human right, one that is given to all. I have had more than one person reply to this sentiment by saying “yes, it is nice to see at least some of your tax money coming back at you.”

I no longer have an anxious patient worried about their co-payment or deductible. Or the asthmatic patient who “bounced back” to the ED because they could not afford the prednisone, and now is in worse condition. Those stressors are no longer existent.

Colleagues

At least ten different countries represent the nursing pool in the A&E including Philippines, South Africa, Australia, Ireland, India, and Burma to name a few. We all choose nursing not for the high pay, nonexistent here, but for the desire to help people heal. We all come with different training and experience and we united to help those in need, a melting pot of nursing. Some with strong community ties bring food for each other and I often walk into the break room with a curry based picnic of sort.

The Hill

I wake up nearly every morning tired and sore from being on my feet for twelve hours, climb on my bike in the bitter cold, wearing five layers to stay warm. I bicycle up the steep hill towards the hospital. Some days I am defeated by gravity early. Others I inch a little further up the hill before I jump off to prevent toppling over. Slowly I push my bike the rest of the way. I know someday I will glide up the hill as though it were second nature. Until then I will keep peddling a bit further every day. The same goes for nursing. I have a steep learning curve and I know someday it will be instinctive to be a nurse in the UK. Until then I will keep learning and growing as nurse as I care for those in need.