In and Out of View - Regarding Mary Seacole

Michael Gove, the Secretary of State for Education, recently announced an overhaul of the history curriculum (of England, Wales and Northern Ireland) to concentrate on traditional historical figures such as Oliver Cromwell and Winston Churchill and to remove figures deemed to be less important, such as the Crimean War nurse, Mary Seacole.

A motley collection of historians have weighed into the debate in support of Gove, denigrating Seacole and plans to erect a statue in her memory. The Daily Mail talks about ‘The Making of a PC Myth’. On the other side of the argument a group of MPs have just tabled a motion to retain her in the curriculum, and publications like the Guardian and The Voice have been articulate in her defense.

One depressing element of the debate is that it often sets up an argument of Nightingale versus Seacole. as if there were only room in the historical pantheon for one nurse, or only enough bronze for one statue, and it sets me wondering about who history is for, and the complex and subjective mechanics by which some get remembered and many forgotten.

For those of you unfamiliar with her name, Mary Seacole was woman of Jamaican/Scottish origin who, after tending the sick in Panama, paid her own way to the Crimea, where she set up a ‘British Hotel’ with food and drink and a clinic for soldiers. She also tended the wounded on the battlefields, sometimes under fire. So popular was she among the military, that when she returned to Britain bankrupt, a three day fundraising concert was set up in her honour which 80,000 people attended and Queen Victoria supported. The press of the time lauded her, and she wore a Crimea Medal given to her by the military. By the time Mary Seacole died in the late 19^th century, her celebrity had faded to obscurity. It is only the last few decades that her story has been rediscovered and circulated.  She is the only black figure on the school curriculum not associated with slavery or the Civil Rights movement.

Not only is it harder for women and minorities to make an impact in a world they do not rule, but even those who have made an impact find it hard to stay in the public eye, their reputations subject to a constant whittling and belittling. Seacole is not truly ‘important’, say Gove’s supporters.

Important to who? She was important enough to the soldiers she cared for that they wanted to commemorate her. Vitally, she shows the historical diversity of Britain, a diversity that some make out happened only in the last few decades. She also stands for the revelation that a black women in the nineteenth century could be wealthy and autonomous enough to dispense charity and care. 

If we don’t see ourselves reflected in our history, we absorb the subliminal message that people like us achieve little.

When Gove picks out Oliver Cromwell and Churchill as examples of who is important, he is a male parliamentarian singling out other male parliamentarians, he is mirroring himself to some degree. Not to belittle anything Churchill or Cromwell may have achieved (and Cromwell achieved much bloody slaughter alongside his honours), but I have a problem with this notion of ‘importance’, as if it is something we can measure objectively.

A man born into wealth and privilege who enters politics and enacts legislation which effects the lives of millions may be doing something important, but he not doing anything exceptional. And as for the kings and queens who Gove is so keen for children to learn the names of, they may have exercised immense power, but that power came to them through the accident of birth or arranged marriage.

I am more interested in people from more modest backgrounds who confounded expectations and had an impact on their times through the exercise of their innate values and talents. Florence Nightingale was one such woman. Mary Seacole another. We need both in full view.

If you feel that Mary Seacole deserves to keep her place on the National Curriculum, you can sign an online petition here

What Nurses Wear - 2

In a previous post about contemporary nursing uniforms, I mentioned the new Scottish uniforms and wondered if patients would find it easy to discern people’s different roles from their subtly differentiated uniforms.

Before Christmas, a relative of mine was admitted to a hospital in the Central Belt, and we were given a small leaflet to help us understand how the ward ran and what to expect. It contained valuable information such as phone numbers and guidance on how to find out what was going on. It also outlined who was who on the ward:

The senior charge nurse, it said, would be wearing ‘a navy blue tunic.’

Check.

Under the charge nurses would be ‘a team of qualified nurses wearing cornflower blue tunics.’

Hmm. A while since I’ve seen a cornflower. Is that a dark or light blue?

‘And clinical support workers in pale sky blue tunics.’

Right, so their blue is a pale one, which means cornflower is probably darker – but not as dark as navy… I think.

‘You may see many other health professionals… such as dieticians, occupational therapists, physiotherapists … wearing mediterranean blue tunics.’

Mediterranean? Mediterranean?

Perhaps some colour swatches might help.

I notice there’s no mention of what doctors or consultants wear, or where to find them. Yet while my partner’s father spends weeks waiting to be discharged, nearly all of our enquiries lead to their invisible persons, and the need for them to sign something or decide something before anything can move forward or resolve.

Another sartorial indignity I came across during the year is the Do Not Disturb apron. The motivation behind it is no doubt a sound one, to minimise mistakes in drug rounds by minimising interruptions, but as so often with good intentions, it is debatable whether it achieves its ends, or whether turning nurses into red warning signs/ sandwich boards does anything to foster a caring and humane atmosphere on the ward.

Nurses I have talked to say that many colleagues don’t ‘obey’ the edict on the apron, and talk to them about whatever is pressing, apron or not. A study reported in the Nursing Times found that these tabards reduced interruptions on average from six to five. Not quite as effective as their inventor must have imagined. 

A New Year

When I started this blog in April, the idea was to keep it running until the end of 2012, the official end of my Leverhulme Residency. However, it’s been so successful at reaching a wide readership that we’ve decided – with the significant assistance of Pam Smith, Head of Nursing Studies – to keep going into the new year, so that I might get the chance to write about people and events that haven’t made it into posts yet, and to publish more writing by nurses.

And on that note, I’m very happy to be including a new story, a story about stories, by Jessica MacLaren, one of the postgraduate students in the department with a background in psychiatric nursing. You can read it by clicking on the Writing by Nurses tag above.

Susanne Kean: Beyond Intensive Care

Early on in my Edinburgh residency, I met Susanne Kean, a former critical care nurse and now a research academic. It was Susanne who first sparked my interest in the world of intensive care, a thread that has run through my writing over the past few months. Over coffee that morning, she talked about the experience of the patient in ICU, mentioning delirium as one of the worst aspects.

‘What’s the difference between delirium and dreaming?’ I asked.

‘You can wake up from a dream.’ said Susanne.

It reminded me of a time, years ago, when my father was in intensive care in Dublin. The line our family took was that his delirium was a kind of blessing – he knew nothing of his illness, was ‘out of it’ in a dream of his own making. Looking deeper into the ICU experience I now realise we were comforting ourselves with a falsehood. Delirium is more usually terrifying for patients, nightmarish, and incorporates strange interpretations of the uncomfortable procedures necessary for their medical care. Patients often think they have been kidnapped, or subjected to torture.

Susanne’s current work is to look at the experience of ICU survival for patients and their families. When I asked what had motivated her to enter nursing, it turned out that concerns of families and intensive care were there from the very start. When Susanne was eight , her two-year old brother became dangerously ill with meningitis. At that time, children were not allowed to visit the ICU, so Susanne and her sister knew what was happening only through witnessing the upset of their parents. She hated being excluded and she resolved to become a nurse.

"I am the knitting one – this being ‘in’ in the 1980s. 
The other two are my friends and we were waiting for 
exams. We had to ‘dress up’ for those."

Susanne graduated in Germany in the 1980s, when the hospital system was very task based – wards served 38 to 50 people, which meant taking up to 50 blood pressures or temperatures each round, and not getting to know the patients very well at all. She then moved to Switzerland where a very different system was in operation. Nurses looked after all the needs of fewer patients, and planned the care with the patients. It was a radical change for Susanne, who at first found the new system very slow, until she realised it was not about completing tasks in an efficient time, it was about basing care around the patients needs, rather than the system’s. This principle has defined her work ever since.

This interest in developing a quality relationship with her patients brought Susanne into intensive care nursing, where there is a one-to-one relationship between nurse and patient. I’m struck by the way that Susanne, throughout her career, has constantly moved forward, questioning the way healthcare is practiced and searching for ways to improve the experience of patients.

 "Shift handover in our kitchen. I was working as a
nurse on a septic surgical ward and loved it!
The other person is our charge nurse."

Her bedside nursing career ended when she developed back problems – sadly common among nurses. She went into management and teaching, but was soon drawn to the relatively new area of nurse-led research.  Britain was further ahead of Germany in the development of this and Edinburgh University was especially strong. Susanne learned English to access the research and did her Masters, and Phd here. ‘Research gives you evidence, and evidence gives you clout.’ she says. ‘Otherwise, people will not listen to you.’

She is now part of the inter-disciplinary critical care research group based in the School of Health in Social Science, carrying out a ‘longitudinal’ study looking at how patients who survive the ICU experience fare over time, not only their physical health, but the psychological, emotional and social effects of the stay.  A recurring theme of her interest is not just the patient’s health, but also the effect on the families and circles of friends who support the survivor.

‘An important but invisible aspect of nursing is establishing a relationship with the patient. In an ICU it is difficult to establish a relationship with the patient as they are normally sedated and attached to a ventilator which prevents speech. Even so, you talk to them, explain what you are doing, even if you don’t know if they hear you or what they can make sense of.’

In this setting, families provide the opportunity to get to know the patients.

‘In an ICU you don’t withdraw when the family visits, you have to stay with your patient. Nurses get to know family members well, and the families have someone on hand to talk to about the patient’s condition.'

'Families are fascinating. Each family member is different, and have different needs. One may want to know absolutely everything in the tiniest detail, others want to know no more than the general direction we are travelling in. Balancing those needs in a single communication is difficult, but they are part of the story, they are the people we discharge the patient to, you need to include them.'

A lot has changed since Susanne was kept from her tiny brother’s bedside by a system more concerned with it’s own efficient running than the wider effects on the families concerned. A stay in ICU is always a traumatic event, and the ripples of that event change patients lives for a long time, and those of their friends and family too.

"I grew up and for a while I loved to ride motorbikes.
This was while working in ICU!"

Plastic People

 I recently attended a lesson at the clinical skills centre at Little France  – I wanted to see students working with simulation models – dummies, in other words. The point of clinical skills is to get some hands-on experience in a scenario as similar to life as design ingenuity and latex technology can get you. And these days, that’s startlingly close.

The room was the size of a small ward, even had curtains and rails to divide the space into a three bedded unit. That’s not what you notice first, though, since you’ve just stepped into what looks like a charnel house. There are single arms everywhere, resting on bloodstained pads (as a dog owner, I recognise these as ‘puppy pads’ a central but largely useless part of canine toilet training – I’m glad they've found another purpose).  In the old days, apparently, you practiced your syringe skills on oranges. Now we have disconcertingly lifelike arms with veins you can inject into or draw from. The blood is a jollier, more fluorescent red than the real stuff. Each arm has a bag of it attached by tubing, giving the impression that someone has just stepped away from trying to revive it.

Around the edge of the room, a selection of anatomically detailed lower torsos sit on the countertop. I wipe the unbidden image of an Amsterdam sex shop window from my mind. The class I'm attending is a speedy overview of pregnancy and childbirth given by the cool-headed Carol Brown, who has brought many of these female parts with her, some in a box branded with the name of Adam, Rouilly, who specialise in such things. The box is printed with the jaunty strapline Limbs and Things. A lone male bottom is incongruously stranded amongst the female parts, very obviously waiting to have his prostate felt. Carol puts him aside.

She props up an entire pregnant female torso, and with a whisk of her wrist pulls down the outer skin to reveal an amazing sight: a full-term baby inside a see-through sac with placenta attached. There is pump to control the inflation level inside the sac, so that manual examination of the belly will be as near life as possible. Some speakers are fitted to reproduce foetal heartbeat sounds. It is both ingenious and oddly beautiful.

The first year students and I practice internal examinations, then deliver the model of a baby through a skeletal pelvis, then a fleshed-out dummy. Between tries, students absentmindedly cuddle or rock the plastic newborn. I even learn something about neonatal resuscitation. Although the lesson is intended as an overview, so persuaded am I by the experience of hands on dummy-nursing, I go away with a delusional idea that if someone went into labour in the aisle of Sainsburys, I might be of some help. A little learning, as they say.

Adam, Rouilly’s website is absolutely fascinating, with an overlay of weirdness for the casual visitor. The list of simulation models makes it clear that this kind of virtual practice concentrates on the more intrusive tasks – injections, intubation, catherisation, internal examinations, suctioning.  Ideally, nursing and medical students can use them to come to terms with the basic mechanics of the thing, so that, when it comes to dealing with living patients (I was going to say breathing patients, but some of these models do breathe) they can focus on the person as much as the task.

But – and it’s not a huge but, because I can see the good of all this. But. Look at the picture below.  As the mannequins become more sophisticated, could it be that healthcare professionals might start to compare us unfavourably with these plastic people – uncomplaining, unopinionated, can’t use the internet, don’t mind waiting for hours, extremely high pain threshold. The students have time to discuss things amongst themselves as these attractive ladies wait in wistful silence, putting the patient back into patients.

All photographs courtesy of Adam, Rouilly

New Writing

I'm very happy to be publishing some more new writing on this blogsite, work that has arisen from workshops I gave within the School of Health in Social Science (of which Nursing Studies is a part) and also a poem sent to me by Denise Taylor, a nurse and writer based in the Borders. You can find Denise's poem along with a memoir piece by Marion Smith under the 'Writing by Nurses' tag above. 
Strictly speaking, it should read 'Writing by and about Nurses', as Marion's story deals with the patient's perspective, and a nurse you wouldn't choose to encounter.

In a similar vein, but a very different setting, Eliane Du's remarkable true story below, has at its heart our expectations about how healthcare professionals will treat us, and the painful shattering of those illusions.

The Doctor With A Gallon Of Water

By Eliane Du

We generally believe that doctors are meant to save lives within their power and ability, but from my experience that is not always the case.

Several years after the Vietnam War ended, my mother decided to leave the country taking her four children with her. It was a drastic decision, but like many Vietnamese “boat people”, we had to risk everything, including our lives, to find a new life. Our transport was a 19½ feet boat crowded with over 285 refugees.  I was about nine years old and was too young to understand how dangerous the journey was.

The night we left Vietnam, my mother dressed us in two layers of clothes and I was given a canteen of water to carry for the family. When we got on the boat, I was immediately separated from my family and was put to sit at the bow. My older brother and sister were pushed down to the lower deck.  My mother and youngest brother along with other children and mothers could remain on top.  

I was very seasick and the horrible smell from the diesel engine made me vomit. Terrified of moving around, I tried to lie still and go to sleep. I woke up with a terrible fever: I tried to look for my canteen of water but someone must have taken it while I was asleep. Our boat tossed and turned heavily in the strong winds and ferocious waves. A big storm was coming and everyone started to panic.

My mother was worried that I might fall overboard without anyone noticing, so she managed to persuade the people around to help and bring me over to her side. Right next to us sat a doctor and his wife. My mother asked him about my condition as I lay dehydrated. I could not take my eyes off the big gallon of water that was placed beside him. I whispered, “water”.   He looked at me and said that I had a high fever. Poor mother, she tried to beg him for a small cup of water but he refused to offer any. Eventually he poured out a little water using the tiny lid from the gallon and gave it to me to stop her from nagging. I was shocked by the amount of water provided, especially from a doctor whom I thought should be kind and helpful. I looked at him and tears were rolling down my face, but he was not bothered. I forced myself to sleep so that I would not think about the gallon of water.

I dreamed that I was happily playing in the sand with the neighbor kids. Suddenly, a big wave dashed in, knocked me down and carried me out into the ocean. I was waving my hands but no one paid attention. The waves kept pulling me under and I struggled to keep my head above the water.  I opened my eyes and felt terrified. It was only a dream but the thought of drowning made me shiver. Around the boat, dark fins loomed up through the water. My mother said softly, “sharks” and told me to pray hard and I again drifted into unconsciousness.

I was woken by something cold going down my throat. My mother was trying to squeeze some lemon juice into my mouth. Someone had thrown us a few lemons and that was how I survived for the next four days before we were saved by an oil tanker. I remember how much I enjoyed those lemons: every single piece that I could get from the little fruit. There was no sour or bitter taste in them but only juiciness and deliciousness and they were far better than the doctor’s gallon of water.

Photos from the journey:

This was the boat on which we left Vietnam. It was 19 and a half feet long and carried  more than 285 people

The rescue by oil tanker. Passenger had to board by ropes and a net.  I remember my mother was almost crushed between the two boats when trying to climb over. Fortunately, someone saw what happened and helped to lift her up!

Eliane Du is originally from VietNam. She has lived in Malaysia, the United States, and the United Kingdom. She received her BA degree from California State University Northridge and an MSc degree from the London School of Economics. She is currently doing her PhD at University of Edinburgh in the department of Clinical Psychology, School of Health in Social Science. Her research interests are in E-Mental Health and Human-Computer Interaction. Before starting her PhD, she had worked as a Software Quality Assurance Engineer for Autodesk Incorporations: an inventor of AutoCAD application and their 3D visual effects, media and entertainment software were used in Avatar movie

Story workshops with nurses

If you scrutinise the photograph (left), you may notice that an essential part of running a writing workshop for nurses is baiting the trap with a selection of finger food. There is no better way to lure busy team members in the middle of their working day.

Along with Dr. Deborah Ritchie of Nursing Studies, I ran four lunchtime sessions for mental health nurses at the Royal Edinburgh Hospital, under the theme ‘Telling our Stories’. Our immediate aim was to generate fresh accounts of mental health nursing today. Not only for the pleasure and satisfaction of the exercise, but because the voices of nurses are so often missing in debates around healthcare. In the long term, we are interested in seeing how these kind of creatively generated stories could be used to inform research, planning and advocacy.

We were assisted by the wonderful arts organisation, Artlink, who run a range of creative activities for patients at the hospital. They kindly loaned the big kitchen at their Glasshouses base so that we could get away from the usual training room atmosphere and have a space that was more homey and informal.

A big thanks to all the nurses who took part, none of whom had done creative writing before, but who rose fearlessly to the challenge, producing work that was moving, funny, sometimes frightening and filled with a tough-hearted dedication.

The following was written by staff nurse Jo Dunlevie in response to a challenge to find metaphors or images that would capture the transition between work and home. It’s a fine piece of imaginative writing.

Work

Unfunny clowns in dangerous big shoes

Stomping animals growling in the dark

Bright lights, Loud horns

Blinking light to dark

High wire ooh's and Ahh's

A moment away from a fall

A Disaster, head off in the lions jaws

Home

Slow steady smiles

Big laughs and tiny giggles

Quiet steady light, and the smell of growing things

Friendly voice, nudging concern

Big sighs and lashes on sleeping cheeks

Soft fall of turning pages

And the Dum de dum of life in Ambridge