On the way home from an appointment a few weeks ago, I turned the radio on, and heard actor Helen Mirren being interviewed. She was talking about the importance of self-worth. She was suggesting it was often in short supply for young people these days as they felt the value they contributed was not enough.
This point struck me because I’d spent the day shadowing Queen’s Nurse Sam Whatnell, a community district nurse working for Cambridgeshire and Peterborough Foundation Trust. And it made me think that self-worth was certainly not something I felt Sam ever needed to be concerned about.
I’ve written about community nurses, met them and like to think I champion them, both through Nursing Times and my role as a trustee for The Queen’s Nursing Institute. But seeing the work of a district nurse up close and personal for a day gave me a whole new perspective on this important part of the profession.
This is nursing at its rawest – its kindest, its most delicate, its most compassionate, its most sensitive – but also its ugliest.
Sam’s caseload for the day was fairly standard, she told me.
We visited older people who relied on her to check how well they were managing their diabetes, a young man who now needs nurses to provide him with daily bowel care, a woman with leg ulcers and eczema, and another with leaky legs caused by lymphoedema.
It was a caseload a practice nurse might see in a GP surgery, and Sam could have been carrying out the treatment and care in an acute ward or care home. But there was something different about seeing these patients in their homes, witnessing how they lived and treating them on their home turf and therefore their terms – it gave her an insight other nurses don’t get.
“In their own home, patients feel more empowered… it’s easier for them to ignore health advice”
Sometimes we were able to meet their spouses or carers so Sam could check how much support they were getting. And if they lived alone, she could offer the advice and friendly ear a partner or spouse might offer.
She could see how likely it was that they were or could follow the regimens she was recommending in terms of diet or treatment.
Take the woman we visited with leg ulcers and eczema. Let’s call her Ms Carter to protect her anonymity. Sam washed her foot and leg, and while she did so convinced her to keep wearing her compression stocking on the other leg – her so far good leg.
Ms Carter wasn’t happy about it and didn’t enjoy the tightness of the stocking. But Sam explained carefully why it was needed to help the blood vessels in her legs to keep doing their jobs effectively.
On the coffee table, there were grapes and sweets. While Sam expertly tended to her eczema, she asked about Ms Carter’s diet. She told Sam she was eating – cakes, tarts and soup. “What about some eggs and cheese for protein?” Sam gently asked.
Ms Carter declared she just didn’t fancy it. As Sam stood to leave, Ms Carter asked her what she could do to prevent her legs from deteriorating in this way.
Sam had given her fairly comprehensive advice, but the woman hadn’t heard it. But when I mulled it over, I think I understood why.
In a hospital, patients don’t want to be there, they will do whatever the doctor or nurse tells them to do to get better so they can return home. In fact, some may believe the doctor doing the rounds or a nurse performing observations have authority over them – they think the health professional can decide whether or not they can go home. There is a huge incentive, therefore, to follow that advice to the letter.
In their own home, patients feel more empowered. They have more freedom to do what they want – and it’s easier for them to ignore health advice – however patiently and sensitively it is communicated to them.
“Sam has a power that’s different to that of her peers on hospital wards – and it’s one she obviously loves.”
But despite this, community nurses must go back into those homes, day after day, week after week, and continue to deliver that same advice – and do their best to be heard.
Sometimes, Sam says, you have to be candid, blunt almost. “I’ve told patients, if you don’t do this, you’ll die. Is that what you want?” she says. “Sometimes they need that honesty and that shock to stop life-threatening behaviour.”
Mostly, what Sam delivers though, is not brutal. It’s familiar, personalised, helpful and compassionate.
Sam might return to her team for lunchtime meetings and can speak to her managers if she believes there are safeguarding or complex clinical issues, but on the whole the thing that is most different about the district nurse role isits autonomy – to some that might feel like isolation.
If Sam wants to make a decision about her patient, it’s down to her to make that clinical decision in that moment, if a patient does something unexpected, she must cope alone.
It’s a power different to that of her peers on hospital wards – and it’s one she obviously loves.
Her day involves a variety of visits and consists of complex holistic assessments with diagnostics and tests. She clearly enjoys getting to know the patients and their families and friends – and she’s helping them live independently with those people around them.
One of the most moving and emotional visits of the day was to a man with rectal cancer who was receiving palliative care.
His wife welcomed us into her home and ushered us through to his bedroom, which was light and comfortable, and his wife perched on the side of the bed, emanating remarkable strength and cheeriness. The man lay there with quiet dignity while Sam dressed his quite distressing wounds.
“It might be the last time I see him,” Sam told me as we got back in the car to leave. “He got through Christmas, and his daughter’s birthday in the new year, and I think he’d been hanging on for your visit.”
I felt honoured. Seeing that man in his home, so close to his death but accepting it with such quiet dignity was a privilege. A privilege Sam also felt too.
She confided his wish had been not to go into a hospice, but to die in the home he told me he’d lived in since the late 1930s, in the arms of his wife. Sam’s clinical skill in caring for him in his own home made that possible – in a way that might not have been a decade ago.
“We can make that happen,” Sam told me. And you could tell she was proud to have the ability to grant this man’s dying wish.
It is a skill and a power of district nurses that most certainly means that Sam’s sense of self-worth is quite rightly intact.