by Dinah Latham
I’m just beginning to wonder whether, in another life or time, I might have become a hermit and lived in a croft on an isolated hillside covered with sheep. I cheer myself up, remembering that my handbell ringing leisure activity is definitely not undertaken alone and I know how much I enjoy playing music as part of a team. This reassures me that I’m not on the road to becoming a complete recluse.
* * *
We’re having a fantastic day here at a real live sheepdog trial. Harriet’s whining enthusiastically, with stifled yelps escaping whenever the sheep come within range; she’s absolutely sure that she can do a better job than the dog on the course, if only I’d let her have the chance. It’s great to see how many shepherds still have difficulty controlling their dogs, even at this level with years of experience. I just want to stay here all day soaking up the atmosphere. Another time, another life, maybe I could have been here herding sheep with my very own dog…
Harriet soon gets bored with only being allowed to watch, and takes up her place lying behind the bale of hay I’m sitting on, attached to my wrist by the lead. Attached to me only because I’m not a hundred per cent sure she wouldn’t dive into the field with the sheep if I gave her half a chance; so I’m just making sure. I’m quite pleased to be here today, resting her a bit, because she’s got a small cut to the side of her front paw where she caught it on some barbed wire and I’ve dressed it with a rather neat bandage. I’m glad I haven’t quite forgotten all those practical bandaging classes from preliminary training school. Sister Stedding would be quite proud of me. I didn’t drop the bandage once. It’s even stayed clean looking. I think Harriet might sleep for a while.
I should have been suspicious of the extended period of stillness; something that was not normally a part of Harriet’s daily routine. There were those times with young children when a quiet interlude was a silent alarm that required immediate attention, but somehow the pleasure induced by the hush tended to lead to a delayed reaction; always a mistake as there was always something afoot. Afoot indeed, Harriet has removed the bandage. Evidently, the tried and tested stealthy teeth method has proved successful, her secret exposed by threads of cotton bandage hooked over a front tooth and hanging from her jaw.
* * *
11
MY RETIREMENT ‘DO’
I found a new walk with Harriet today. We had circled round another footpath that I didn’t know existed and, as we followed the path round the edge of the field, I was taken aback to find myself gazing over the hedge into the back garden where I had held my retirement party a few years ago.
Harriet is busy with her nose buried deep in the pile of leaves, evidently tossed over from one of the neighbouring hedges in an attempt to rid their lawn of debris. She rolls over on her back and wiggles backwards and forwards in her favourite play position, waving her legs in the air.
I turn back, to again stare at the garden. One of my sons was renting the house at the time and it was just the place I needed to enable me to invite special work friends to a leaving party.
It was still a beautiful garden now on a chilly, rather grey, winter’s day, but my mind’s eye immediately leaps to that warm summer evening here, with the marquee, the three piece jazz band, the laughter and the chatter.
* * *
I had carefully planned my retirement party. I so wanted those who came to be people I really wanted to be there; I had refused to have the usual leaving party given by management to supposedly ‘thank’ me for my past years of service. I had spent too much time, particularly in recent years, fighting management on several levels. I knew I was a ‘thorn in their side’ and that any ‘thanks’ would be false – why then would I want anyone from management at my party? But they have to come, I was told. It can’t happen without, it was said. Well, it can and it did, and it gave me great pleasure to only have people there who were truly sorry to see me go.
Colleagues from various genres of my previous practice areas came. It was an exciting party that meant so much to me. Nurses, past and present, had travelled so far and given up their precious time to come and be part of it all. I’d sent invitations with a photograph of me right at the beginning of my training, dressed in what now looks like a really old-fashioned nurse’s uniform: crisp white apron and butterfly cap. It’s a treasured event that I’ll never forget and, even now, every one of those friends who came to share it all with me has a very special place in my heart and in my memory basket. Surprisingly, the significance of the event has grown for me in the years since it happened. Rather than diminishing with time, the presence of so much care for me seems to have provided a slow motion recording in my head of it all, and I replay it often. And here I am, unbelievably, almost seeing the event again but in real time!
While it was principally a party celebrating my retirement from my district nursing post, I also invited some colleagues who had shared my lecturing life with me, which added to the vibrancy of the gathering. I had run these two parts of my career concurrently, primarily because I believed so much in the practical application of all the ‘science’ of nursing that I wanted to continue to practice as well as to teach. I also held fast to the principle that those of us who choose to teach the skills need to be practising them to keep the ‘art’ aspect of nursing alive. My teaching experience taught me that too many nursing lecturers are far removed from the practical application of all they are teaching. Indeed, a considerable number were from disciplines other than care, again accentuating the scholarly, rather than the nursing, context of the learning.
* * *
I find I can’t draw my gaze away from the garden, with all the memories flooding back. I’m rooted to the spot; looking across the lawn to a small patio. The benches are still there as they had been on my party night, a little way away from the marquee, with a green climber on the wall behind. It has now reached a good bit farther up the trellis, looking strong and vital, despite now shedding its leaves. As I look across, I remember the group of medical and lecturing colleagues that had congregated there, chatting…
* * *
It was good to see these two halves together; medical and lecturing colleagues, with me being the common link. One of my lecturing colleagues described watching me manage and control three hundred students in a lecture theatre, holding their attention with stories straight from nursing practice. I’m smiling now as I remember glancing over to see one of the GPs, his hands cupped round his mouth imitating a loud hailer, shouting, “She’s been managing me for years!” Everyone laughed and he went on to tell stories of joining the practice and how great it was for us to be able to discuss families together, to make joint visits, and how that working relationship benefitted patients.
I reflect now on how long it took us as district nurses to become attached to GP practices and how, previous to that, we used to work in patches, an area defined by four roads, serving anybody who lived within that ‘patch’ no matter who their GP was. When we became GP-attached, it meant that district nurses worked much more closely with their doctor colleagues. This GP attachment was considered a real achievement within district nursing: to be able to discuss the patient’s needs directly, with feedback from both of us on progress, really targeted the continuity that families appreciated so much.
I gather this whole idea of district nurses working closely with the GP is well on the way out now. The GP used to meet with the district nurse attached to his surgery to discuss and hand over details on any patient he wanted his district nurse to see. He now has to make a referral for care to a central point; to an administrator for triaging. The administrator will then divert that visit anywhere, to any community nurse who has a list of visits on the computer that shows she has minutes to spare today, i.e. dependency code deficit! Unfortunately, there is no code that accounts for the patient who may need more time today than just the giving of her injection, and who may really want to see the same nurse; the one he knows and trusts.
I remember the speeches going on well into the ni
ght with colleagues. The doctors I had worked with talking about patients we had visited together – touching stories; humorous stories.
Even as I listened then to kind comments on my personal commitment to patient care, I had a very strong sense that what was happening here was not only a goodbye to me, but rather a goodbye to an era. This celebration was somehow farewell to a time in nursing that had almost disappeared, to a time when it was apposite to consider nursing a vocation – when to talk of ‘serving’ was not a cause for sniggering laughter and when the oft hidden art of care was acknowledged alongside the science, both being equally valued.
There was a time when students came into the profession driven by a desire to become experts in this art of caring, rather than how they enter now, with aspirations of impersonating the doctor by running around with intravenous drugs in a kidney dish, feeling important.
When did it change? I suspect it was when nursing management took precedence over those undertaking ‘hands-on’ care and when it was deemed that the apprenticeship model of learning this caring art was unsatisfactory and that a degree was necessary to nurse.
To some extent, we, as a profession, have ourselves to blame for the swing to university education being adopted as the way forward. Nurses began to rebel against the vocational aspect of nursing; the way of describing it as ‘a calling’. This became not just unfashionable but something to rise up and challenge, and it went alongside nurses shouting loudly about poor pay. There was a constant push for payment for unsocial hours and the battle was won with night duties and weekend shifts reaping increased financial rewards. I never empathised with this wave of discontent, believing we had entered the profession knowing it was a twenty-four hour, seven day a week job, so I never understood why working any of those hours was deserving of more money. No-one who longed for a nine-to-five job would ever have considered nursing.
What followed this was the reduction of staff numbers rostered at the duty times that demanded higher rates of pay, with fewer members of staff to undertake the same levels of care at unsocial hours. Patients are ill as frequently at weekends and nights as during the nine-to-five weekday hours, but they are served by fewer, less qualified (and therefore cheaper) staff members. This did not happen prior to this change in pay scales. Of course, there were societal changes elsewhere across the board, but nursing had previously always been considered a separate case; one that didn’t conform to changes that would disadvantage patients. As I remember it, this was the point when there was a change in attitudes.
What seemed to follow on from this somewhat militant demand for more money was an undercurrent of ‘we’re worth more than this’ and ‘what we do is sufficiently important for us to get a degree’! Again, there was a push for many more people to complete a degree – in almost anything it would seem – with very little consideration given as to whether or not it was always the best way to learn a particular craft. The tables began to turn. Nursing students were to become academic students attending university to learn what was fundamentally a practical skill: caring for the sick.
I don’t think anyone in the profession would deny the need for higher education further up the career ladder, but a growing number of nurses are beginning to question whether this is the best, the most successful, way to learn how to care for the vulnerable members among us.
Shortly before I retired, I had a student nurse allocated to my area of practice for two weeks to attend patients with me, to observe district nursing work. We visited several dying patients and their families. At the end of the first day, I was really taken aback when she asked, “Which course is it I need to go on to learn how to talk to people like you do?” We went on to talk about how getting an A for her latest essay on communication skills had failed her because she felt unprepared to ‘talk to people who were upset’.
I wonder if those nurses who pushed so hard for what we’ve got now have ever considered that the old adage about ‘being careful what you wish for’ might have a real ring of truth about it in this instance.
* * *
I look across at the large Magnolia tree in the far corner, with its garden seat and table. There are no Magnolia blooms now and, even at my party, the tree had finished flowering; but the canopy formed by the leaves was thicker and the green of the leaves more vivid. It is a magnificent tree with a mock streetlamp standing tall at the far end.
* * *
It was here, under this tree, when the last guest had left, that I had sat and read the many cards that had been sent or brought with the many presents that adorned the table. My four children were busy clearing the remains of the party, while I sat with a last glass of wine and read each card with its cherished words.
The first card had a picture of a large mother bird on a branch hovering over her nest of fledglings. The speech bubble from her beak said, ‘Goodbye and Good Luck!’ As I opened it up, the handwriting said ‘I’m a better nurse because of you’. It was signed by Maria.
I had taught Maria during her training. She was a keen student and I was really pleased that she had attained the post she wanted.
Maria was one of the trainees I taught when I went into nurse education, after it moved from the old ‘hospital school of nursing’ model of training into the university.
Following this decision, the whole focus of training changed. The emphasis now was getting the students through their degree programmes with more time spent in ‘school’ and less time on the ward, thus accentuating their academic student status, rather than highlighting the real learning to be absorbed by ‘doing’ as a junior member of the workforce.
I took the position of senior lecturer because I believed we had to redress the balance and, I suspect, I believed I could inspire nurse trainees with a desire to care, and so encourage the art alongside the science with stories and more stories of ‘care in action’.
I summon up Maria in my mind: she was one of about fifty students who had come to learn about pain management for dying patients. I recall how they had all come with pens and notebooks poised ready to list the necessary drug names, dosages, and side effects. I remember the session well. The quizzical faces indicated that they were startled to learn that it wasn’t all just about the where, when and how of drug regimens but, more importantly, it needed their ability to ‘be with’ their patient, to listen to the meaning of the moment for them, and to validate their pain experience; to reassure and to comfort them.
Again, standing here today I feel I am watching a replay of my retirement party. I remember that Maria had come to me after this lecture and told me she’d learned something special that day: she’d learned what the essence of nursing was all about, she said. I was touched by her words.
* * *
I laugh now as I glance over to the tree and recollect the warm evening and the light from the lamp as it fell across Maria’s card. At the bottom of the card she quoted me:
‘Pain is a huge experience that cannot be sorted out by just the giving of an analgesic!’
* * *
Thank you, Maria, for giving me this feedback. Maybe my voice was not always crying in the wilderness.
Maria’s card and comments made me think of my conversation with the Dean at my exit interview before I retired. She asked if I could offer any reason why I had such a consistently high attendance record from the students (there is no compulsory attendance required as a university trainee nurse student!). I responded, saying that on the feedback sheets that the students submitted, there were always comments about how great it was to have real life stories from someone working out in practice to make the learning live.
It seems as though the students themselves are asking for more ‘hands-on’ learning. They themselves are perhaps feeling that their placements into different areas of practice are not giving them sufficient experience to maximise their learning; to match the theory to practice and put it all together.
* * *
The picture of the garden stayed vividly with me as
I returned to my walk. The sound of happy voices, the jazz band playing, the clatter of cutlery on plates amidst sudden shrieks of laughter, seemed graphically there in my head. I could feel the cards and letters in my hands and I remember putting them away later with other letters I had received from patients and relatives.
* * *
I had kept them all and, as I walked, I sifted through them in my thoughts. Many of the letters were from family members thanking me for the care I had given to a loved one…
A grateful son thanked me for the many conversations I had had with his ninety-year-old mother, Martha, with her sharing her feelings about wanting to die now. Her immobility and loss of independence had become huge burdens for her and she explained what a relief it was to be able to talk about it to me; her innermost thoughts being too painful to discuss with family. This somehow enabled her to manage a little longer, knowing that the opportunity was there to offload with someone who was ‘her nurse; a professional who offered her the understanding and the confidentiality she wanted’. I knew there would be no support offered to other Marthas now. There would be no allocation of time by a district nurse to the increasing number of Marthas in our community anymore.
She wouldn’t justify a visit now; after all, what ‘nursing need’ could be applied to her affliction? What dreaded dependency code could be allocated?
Like pages fluttering over in a book, more cards and letters flashed in front of my mind’s eye. My thoughts then rested on a rather scrappy piece of paper with only a few words on it.
Georgie
Georgie was only forty-two years old when she died, in her bed by the window, looking out on to the garden she loved so much. Her cancer-ravaged body was painfully thin with sallow skin stretched over bony prominences, while her abdomen was incongruously distended with fluid. Any movement was exhausting for her.
