Other NHS hospital staff (Part 1)

As there are so many different types of nurses, I’m only going to talk about them in this post. In the next post, I’ll deal with some of the other groups of clinicians you might encounter during a hospital stay.

Nurses

If doctors are important to the safe and effective running of a hospital, the nurses are downright indispensable. A hospital without nurses is the worst hotel you have ever stayed in – it’s noisy, particularly at night, lacking in privacy and with shared toilet facilities. The air is unpleasantly scented with notes of disinfectant, vomit and poo. The food is average at best, and the place isn’t licensed, so you can forget about a liquid diet. You risk catching this or that horrible infection from one of the other guests. Rather like the Hotel California, the number of guests checking out is significantly lower than the number checking in. Part of the all-inclusive entertainment package may be to witness the dramatic resuscitation of a fellow guest. Will they live? Will they die? Worst-case scenario: the fellow guest is you.

A hospital properly staffed with trained nurses is a place where patients receive the best possible, high-quality, compassionate care. Nurses are by far the largest group of clinical NHS workers, with current figures indicating there are roughly 350,000 of them. When midwives and health visitors are included, they make up 40% of the total NHS workforce. Even so, there are over 25,000 nurse vacancies. This figure would be much higher if it were not for the fact that many vacancies are currently filled by temporary (and expensive) bank or agency staff. Working on the NHS frontline for as long as I did, it was clear to see that hospital wards and specialised departments such as the ICU, the ED and the operating theatres were frequently understaffed. More and more was routinely asked and expected of fewer and fewer nurses.

Unsurprisingly, this kind of treatment knocked the morale of nurses and stressed them out, leading many to abandon ship for less demanding, better-paid jobs with an improved work-life balance. Less pressurised jobs that didn’t require you to regularly make life-and-death decisions. Jobs where you weren’t constantly dealing with suffering, dying and death. Jobs where a mistake didn’t lead to the death of one of your clients or customers. Jobs where you weren’t routinely verbally abused or physically assaulted.

As a result, another perennial feature of hospital life throughout my career was the relentless succession of recruitment campaigns run by hospital managers to plug service gaps. These campaigns often involved managers touring the world in search of recruits from so-called third-world countries in the absence of willing home-grown candidates. The reasons for this shortage are not hard to find. Apart from preferring better-paid jobs with less responsibility and pressure, people with a vocation to become nurses are put off by the tuition fees paid by university students in the UK. Their average accumulated student debt is about £50,000 by the time they have qualified. Crazy! What’s more, no matter how successful these recruitment drives might have been, the influx of newbies entering by the hospital front door was often matched or even exceeded by the efflux leaving by the back door.

The average (median) gross income for a full-time employee in the UK today is about £40,000. A newly qualified staff nurse, after three years of university study and hospital training (and a £50k student debt), earns £32,000. A newly qualified ward sister (or charge nurse) with years of experience under their belt and tons of responsibility just about makes that average income figure. And these are the payments in the NHS. The situation for nurses in the social care sector is far worse.

Rant over, let’s get on with it, shall we? There are about three nurses for every doctor working in NHS hospitals. They come in a dazzing array of flavours: ward nurses, theatre nurses, anaesthetic nurses, recovery nurses, ED nurses, ICU nurses, coronary care unit nurses, outpatient clinic nurses; matrons, sisters, charge nurses (male sisters), staff nurses, health care assistants (HCAs, previously known as auxillary nurses), student nurses; nurse practitioners, nurse consultants, nurse specialists, preoperative assessment nurses –  phew! The list goes on. Even so, as we have seen, there are nowhere near enough of them, and the UK is heavily reliant on importing qualified nurses from other countries to help make up the shortfall.

The job description of a hospital nurse is enough to put off even the most ardent budding recruit to the caring profession. At the top of the list, nurses nurse. They look after the basic care needs of their vulnerable charges who, through reasons of age, infirmity and illness, are incapable of looking after themselves. Nurses ensure their patients are clean, warm, comfortable and safe. They toilet them. They serve patients food or feed them when they are unable to feed themselves. They clear up after their patients if they vomit or are incontinent. They closely monitor their patients’ clinical observations and are trained to recognise when a situation requires immediate assessment by a doctor. They provide social and physical contact for patients. They provide reassurance and comfort when patients are distressed. They dispense prescribed drugs. They put up intravenous fluids. They resuscitate patients after cardiac arrest. They communicate with distressed and befuddled friends and relatives, often relaying in more comprehensible language the bad news that the doctors have just told them. They comfort family members during periods of great angst and grief. Throughout all this, nurses maintain their patients’ dignity.

My first book, Vocation, asks whether I had a vocation to become a doctor. While the jury may still be out deciding that one, there is absolutely no doubt in my mind that you cannot be a good nurse without a vocation to the profession.

Another key role of hospital nurses is to guide hapless junior doctors and to step in whenever they might be in danger of doing something stupid (a frequent occurrence) – or of not doing something eminently sensible (an even more frequent occurrence). A ward sister or experienced staff nurse is like a battle-hardened sergeant major to a newly commissioned 2nd lieutenant (house officer) fresh out of Sandhurst (medical school), who doesn’t know their arse from their elbow or one end of the NHS frontline from the other. The best advice you can give a newly qualified doctor is to always listen to the nurses and act accordingly. This is particularly true if they tell you a patient isn’t quite right, even though they can’t put their finger on what it is. Call for backup PDQ and do an immediate clinical assessment. The chances are the patient is heading towards a cardiac arrest if you don’t identify the problem soon and sort it out.

There is a bewildering variety of specialised tasks that nurses undertake in hospitals aside from the common or garden ward nurse’s traditional role of caring for patients on general medical and surgical wards. The following list is not exhaustive. Apologies in advance to all those nurses reading this whose specialist skills I have not included.

Critical Care or Intensive Care Unit (ICU) nurses

I worked very closely with ICU nurses throughout my career. They possess a unique set of advanced knowledge and skills that are essential to safely manage their ventilator-dependent, critically ill patients with multiple organ failure. ICU nurses have to be highly trained because the doctors are not omnipresent on the unit – they’re often busy assessing or stabilising other patients in the hospital, attending meetings, engaged in interhospital transfers of critically ill patients, and so on. ICU nurses, therefore, have considerable autonomy to take independent clinical decisions, alter ventilator settings, administer powerful drugs on their own initiative, extubate patients (remove their tracheostomy breathing tubes), and perform myriad other interventions. If you are unlucky enough to be at death’s door on a mechanical ventilator in your local ICU, take heart from knowing that you will have your very own ICU nurse to look after you, and only you (the nurse-patient ratio is generally 1:1).

ED (Emergency Department) or ER (Emergency Room) nurses

Probably the most stressed group of nurses in the hospital because most UK Emergency Departments are tremendously under-resourced for the number of patients they treat. Key targets for patients to be seen within four hours of arrival and to be definitively dealt with within twelve hours are routinely missed by such a wide margin that they are almost meaningless. The national disgrace that is corridor care is here to stay for the foreseeable future. It is little wonder that the morale of so many ED nurses is suffering. Calm and organised in a crisis, they are particularly adept at resuscitating patients in cardiac arrest or in peri-arrest situations.

Anaesthetic nurses

Unlike nurse anesthesiologists in the USA, anaesthetic nurses in the UK do not administer anaesthetics themselves (although some of the more experienced ones I worked with over the years probably could have managed a routine general anaesthetic solo). Rather, they assist an anaesthetist in the anaesthetic room and operating theatre. A good anaesthetic nurse is indispensable to the safe conduct of anaesthesia, equally as important as the anaesthetist. This is particularly true in an emergency situation when the shit is hitting the fan.

When I first started practising anaesthesia, I was generally assisted by anaesthetic nurses. However, over the years, more and more of the newer Operating Department Practitioners (ODPs) came on stream, and these now make up the majority of newly-qualified anaesthetic assistants. They aren’t nurses, but like nurses, ODPs must study at university for three years to earn a BSc degree. If you have been reading my books, you will have noticed that I sometimes mention an anaesthetic nurse helping me, whilst at other times it’s an ODP. Now you know why.

Recovery nurses

The happy, smiling face you see after waking up from your anaesthetic is likely to belong to your recovery nurse. If the face is scowling and looks a tad pissed off, it’s probably your anaesthetist’s. Recovery nurses are another bunch of highly trained individuals. It’s their job to manage your airway and breathing while you’re still under – your anaesthetist may well have buggered off back into theatre to start the next case. They will remove your laryngeal mask airway or tracheal tube when it is safe to do so, administer morphine and other powerful analgesic drugs via intravenous injection, ditto anti-emetic drugs if you’re puking up, and generally look after you. It is they who will decide when it’s safe for you to be discharged back to the ward or when to call the anaesthetist back to reassess you if they have concerns.

Recovery nurses are routinely used and abused by anaesthetists, particularly those like me who were also intensivists. Whenever the ICU was full (which was often), I would canoodle up to the nurse in charge of theatre recovery and beg him or her to let me park my overdose or septic patient in the corner ‘just until the morning when I’ll have an empty bed.’ Although the skillset of a recovery nurse does overlap a lot with that of an ICU nurse, managing a critically ill, ventilator-dependent patient in recovery was an imposition and far from ideal. Such requests often led to recovery nurses being phoned at home on their days (and nights) off to come into the hospital and look after my patient. Sometimes a recovery nurse who had been on duty since eight o’clock that morning would volunteer to stay overnight as well, because no one else was available. I never ceased to be amazed by the forbearance of my recovery nurse colleagues, who never bore a grudge and still seemed to quite like me.

Preassessment nurses

Another set of nurses who work closely with anaesthetists and who are worth their weight in gold if they’re any good (which they nearly all are) are the preassessment (short for preoperative assessment) nurses. Back in the day, when I was a surgical house officer and later a junior anaesthetist, patients scheduled to undergo elective surgery usually arrived in hospital without their general health status having been properly assessed beforehand. Yes, they’d seen their consultant surgeon in the outpatient clinic and shown them their hernia or piles or whatever, of course. However, surgeons are about as much use as a chocolate teapot when it comes to preoperative assessment. What your average surgeon knows about heart disease, hypertension, respiratory disease, diabetes, and all the rest you could write on the back of a fag packet. So, it wasn’t unusual for patients to be admitted to hospital for their operations, only to be sent straight back home again because their surgeon hadn’t noticed that their blood pressure was so high, the top of their head was in danger of blowing clean off. Or that their blood was sweeter than your average can of Coke. Or that the recurrent chest pain they had been complaining of for the past few months wasn’t simple indigestion but an impending heart attack.

All that nonsense has changed. Now, as soon as a patient is listed for surgery, they’re booked into the preassessment clinic, where a nurse specialist goes through all their health-related issues with a fine-tooth comb. Blood is taken for routine screening. An ECG, chest X-ray, and any other investigations indicated are ordered and reviewed before surgery. Patients with severe hypertension or poorly controlled diabetes are referred back to their GPs to have it sorted, and their operations are postponed. A patient with recurrent cardiac chest pain (unstable angina) is given an urgent appointment for the cardiology clinic. Other issues are flagged for discussion with the relevant anaesthetist to plan next steps. As a result, cancellations on the day of surgery due to a patient not being medically fit for their procedure are rare. It’s one area, at least, where the NHS is doing quite well.

Theatre nurses

The two main types of nurses working in the operating theatre (excluding anaesthetic nurses) are scrub nurses and circulating nurses. The primary difference is their relationship to the sterile surgical field. The scrub nurse is inside and so undergoes the same full scrub as the operating surgeon, whom they directly assist. The circulating nurse is outside, and their job is to open sterile packages of instruments, pass on sutures, swabs, etc, and fetch additional kit as required. The scrub nurse and circulating nurse, between them, are responsible for ensuring that the all-important swab count is undertaken at the end of surgery and, crucially, is correct. Leaving a swab inside a patient is considered poor form. It is likely to lead to a Serious Incident investigation, a complaint from the disaffected patient and a public flogging for all concerned.

Paediatric/neonatal/SCBU nurses

Considering anyone over the age of sixteen to be geriatric, this group of nurses look after children, infants (children under one), neonates (infants under twenty-eight days old) and premature babies (on the Special Care Baby unit, SCBU). I take my hat off to them and to the paediatricians they work alongside, for what they do. Quite early into my clinical training as a medical student, I learnt that I couldn’t.

Advanced Nurse Practitioners (ANPs)

These are a very highly qualified group of nurses (generally with a Master’s degree) who assess, diagnose and treat patients, and prescribe them certain medications. An ANP might see you in the outpatient clinic rather than the consultant or a junior doctor for the routine review of your hypertension, COPD, asthma or diabetes. An ANP might perform a minor operative procedure on you, such as the excision of minor lumps and bumps or a back injection for chronic pain.

An ANP with whom I worked in the ICU for many years was absolutely brilliant. He knew more about assessing and treating critically ill patients than most junior doctors. I always loved it when he was on call with me because it meant I would rarely be dragged out of my pit in the middle of the night. He would be seeing to everything. Marvellous.

Nurse consultants

These were introduced into the NHS in 1999. I never met one and consequently have no idea what they do. Call me a conspiracy theorist, but I think the role was manufactured simply to make it look like the NHS had more consultants than it does. However important their role may be, there are only about 1,000 of them working across the NHS, making up less than half of one per cent of the entire nursing workforce.

Infection control nurses, aka infection control police

I always used to dive for cover whenever I saw one of these heading my way. I knew I would be infringing at least one infection control rule, meaning it was almost certain I would pass on contagion to every patient I met. If I hadn’t forgotten to take my watch off, my sleeves wouldn’t be rolled up. Or my tie would be wafting lazily in the breeze. Or there was an unsightly stain on my scrubs, the nature of which didn’t bear thinking about. I was at least confident it couldn’t be my unhygienic white coat, because the infection control police had banished those years ago, and I wouldn’t be wearing one. Do you know, there are apparently more germs on your average white coat than there are in your average dog turd. I suppose I should have washed mine more often than once a year.

Educational tutor nurses

Those who can, do. Those who can’t, teach. Those who can’t teach, tutor. Enough said.

Miscellaneous nurses

If you’re a nurse and I haven’t mentioned you yet, you’ll be less than chuffed to note that I’ve included you in the miscellaneous group (or worse, forgotten all about you entirely). I’m sorry if you feel like you’ve been lined up in the school playground, waiting to be picked by the captains for a place on the team, only to find yourself the last man or woman standing.

One reason you’re miscellaneous is that I don’t know much about what you do, having never really worked with you much during my career. The group includes psychiatric nurses, rehabilitation nurses, palliative care nurses and oncology (cancer care) nurses. I’m sure you do a great job and deserve more recognition than I’ve afforded you. Soz.

Summary

Nurses do a superb job. They are fantastic. It must be true because I married one.