It has been a while since I’ve had the chance to post on the blog, so apologies for the silence. In compensation, here is an interview with Shaun Maher, an inspiring nurse who is working to improve patient care across Scotland.
I first heard Shaun speak at an Intensive Care study day, where he talked about what ‘person-centredness’ might mean in this most technological of settings. An ICU charge nurse at Forth Valley Hospital, he was articulate and energetic and introduced concepts that felt fresh- to me, at least – in terms of the dynamics of healthcare. He talked of how his unit had worked to abolish visiting hours, saying ‘The patient’s family are not the visitors, we are the visitors in their lives.’
Another innovation was to allow families to make requests of the staff, on a form with the question ‘What would you like for your family member today?’ Understandably, there was some initial resistance to this among the ward staff – they feared that they would be asked for things they could not deliver – wellness, the miraculous. Yet the actual requests that came in were often heartbreakingly small and achievable, to do with chapped lips or other modest comforts. As Shaun says, ‘Nurses feel “I have only so much time, I won’t be able to meet their needs,” but that’s not the reality. People actually ask for less than we assume they want.’
Since that study day, Shaun has taken up new role – he’s on a two-year secondment with Healthcare Improvement Scotland working on their person-centred care programme. He took up this challenge because, although he could effect change within his own unit, he was frustrated that he had no way to spread this into the wider system.
We met at a café near Edinburgh Park Station – his new post sees him shuttling between offices in the central belt – and I asked him where his conviction and ideas came from. As an influence he cited Harvard professor Don Berwick, an improvement guru who worked on the “Obamacare” reforms in the USA and has just been appointed by David Cameron to head up the National Advisory Panel on the Safety of Patients.
But many of Shaun’s ideas are grounded in his own clinical practice. He tells me about a telephone conversation with a nurse in A&E who had two patients who needed to be admitted to the ICU. One required immediate life-saving treatment, but the A&E wanted to send up the other patient ‘as she was about to breach the four-hour wait limit.’ It is a vivid example of how the needs of patients and common sense can be over-ridden by too much attention to systems and targets. Although what happened at Mid-Staffordshire was an extreme example of NHS dysfunction, it is symptomatic of wider difficulties.
And how do you change an organisation as large and complex as the health service? Shaun talks of ‘Reliable Design’ and ‘Improvement Systems’, and my mind starts to fuzz – it seems to me as difficult as rebuilding an ocean liner as it is crossing the Atlantic. But at the same time I’m very glad that people like Shaun are working on it, are willing to tackle the challenge of finding a way towards more humane and continuous care. And although he is enjoying his time in the policy end of healthcare, Shaun is keen to keep up his clinical practice during this time and ‘stay grounded.’
Although Shaun has many nurses in his family, both male and female, his first jobs were in forestry. ‘I didn’t want an ordinary job’, he says. Soon, he found himself gravitating towards healthcare. His aim was to go in to children’s nursing, but his final training placement was in Intensive Care, and he took to it straight away. ‘I liked the drama, the severity of the situations and the intellectual challenge of the technology and physiology’ He jokes that it appealed to ‘the OCD part of him’, the part that took pleasure in having all his lines straight, in generating checklists and having the equipment arranged just so. But like many ICU nurses I have spoken to, the most important aspect was having the chance to look after his patient properly, to give time to the task. ‘I felt at peace with myself there,’ he says.
‘And although you see a lot of death, paradoxically, that can be a very satisfying aspect of care to work in. People who connect emotionally to the work do the best job, but you have to give something of yourself, and that has consequences.’ He says that every nurse experiences certain cases that ‘get to them’. ‘Perhaps because it mirrors something that has happened in your own life, or simply because of the youth of the patient or other particular circumstances.’ Being able to let that emotion out in a safe environment is important.
We talk of patients’ hallucinations and the psychological agonies of the ICU experience. ‘The brain is a protective mechanism, but people rationalize their experiences as torture, or being in a concentration camp, or that people are doing experiments on them.’ Sometimes, though, the delusions are less nightmarish, more amusing. He tells me of a man who complained about what he perceived as the constant parties that the nursing staff held in the ward. ‘He said that people kept opening cans near him – I think that was the sound of the hand spray units, and sides of smoked salmon – well, the tracheostomy kits come in long silver envelopes, so I think that was it. An interesting thing is that we thought this man was totally back to normal by then, when he wasn’t at all.'
Shaun says that, in terms of the psychological damage, there are three things that can make a big difference to recovery.‘The first is to involve the family or close friends, so that the person can hear their voices and remember them as part of the experience – it helps them feel secure, and it also means those people can help them rationalize what happened when, can remember it for them. The second is early mobilization, and the third is to keep a patient diary, especially for the sickest and most delirious, so that they can reconstruct a chronology of what happened to them.’