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!"

"You'll Never Make a Nurse"

Jan as a young nurse, Ayr, 1964

Jan Clyde is telling me about cycling through the Gorbals:

‘This was early 60s, the last days of gang warfare. Often there was trouble on the streets, and I remember feeling scared, but Sister would say, “Keep cycling. Look ahead. Don’t turn your head!” The thing is, they wouldn’t touch you because they knew you were there helping the community. They’d stop fighting to let you past.’ Jan laughs at the memory now. She was placed with the district nursing team in the Gorbals and would cycle out each day with her supervisor to attend the sick in their homes. ‘I had never seen deprivation like it. People had nothing – nothing but ten children – but they were lovely, and so grateful for anything you could do. The sister I had was terrific. I always say that I learned my complete basic nursing care from her.’

Jan is my neighbour on the Rosneath Peninsula. When we first met she’d just retired after more than forty years nursing in hospitals and the community. This year she celebrates fifty years a registered nurse. I told her that I was trying to write about nurses’ lives and she agreed to tell me some of her experiences.

Like many nurses I’ve talked with, Jan had close experience of illness in her childhood. Her father suffered the aftereffects of a severe fall at work, and became one of the first people to be given replacement hips. However, she credits her decision to become a nurse more to defiance than virtue. Jan, who has a flair for art, wanted to go into stage design, but her mother pressed her to get a ‘real’ job. The subject of nursing came up and her mother opined, ‘You’ll never make a nurse’ and that was it.

‘I was so naïve’, she says, ‘I thought it was all headaches and bandages. But I did take to it, and nursing has been good to me.’

Jan started nursing in an environment very different from today’s. Fierce ward sisters ruled and god help you if you were caught out, as Jan was, occasionally wearing nail polish or with too-high beehive hair or having a run in your stockings. The need for order was paramount. ‘But I liked the uniform, the stiff belt, the apron, you did take pride in it. It’s about respect, and having respect for yourself and your role. When they took the aprons away, and the caps, I just thought, I hardly feel like a nurse anymore.’

Working first at a hospital in Ayrshire, Jan was drawn to a surgical role. Having abandoned her early hopes of working in one kind of theatre, she spent seventeen years in another, as part of the operating team. ‘I like the drama, you see,’ says Jan, a light in her eye.  What she didn’t like was not knowing what happened to patients after they left theatre. Later, when working at a hospital in the Central Belt, Jan and other surgical nurses negotiated a system whereby the could visit patients in the wards to check on their recovery and talk with them. It echoes something I have heard from many nurses – the deep need to find out what happened next, what the outcome for ‘their’ patients was.

I can’t do full justice to Jan’s long career in a short blog post except to mention that she also ran an army medical centre, worked in a cottage hospital and spent the last fifteen years of her career as a practice nurse in a Glasgow community where she enjoyed the sense of continuity. ‘I was inoculating the children of people I had inoculated when they were small.’

Since retiring, Jan has re-connected with her creative ambitions and works as a textile and jewellery artist, but she remains a registered nurse and keeps in contact with former colleagues. Now her niece’s 19-year-old son has decided to enter the profession. ‘I tell him about life on the Nightingale wards and what is was like then and he looks at me as if to say, did you train with Florence?’

Jan is modest about her many skills and the thousands of people who have come under her care and passed out the better for it. At one point she uses the phrase just an ordinary nurse. I think that while the individual acts of nursing may seem ordinary to those that perform them, the accumulation of those caring acts over more than four decades is an exceptional thing.



Gorbals scene 1960s



Professor Tonks

Tonks (centre) with some 2012 graduates

Josephine 'Tonks' Fawcett has been teaching in Nursing Studies since 1982 (‘Of course, I was a mere egg at the time!’). When you talk to students, Tonks’ name arises often – her humour, her habit of turning up during night shifts to visit her students, her perfectionism, her sayings. On first meeting, I was struck by her lithe energy and the individuality of her office – as much sitting room as workspace, with comfortable chairs, kettle ready for tea, and looking down from every wall and shelf, photographs and cards from past students and friends, an international web of nurses.

Tonks has just been awarded a Professorship at Edinburgh, providing an excellent opportunity to persuade her to submit to some questions.

One I have to ask – where did the name Tonks come from?

Well, I was the third girl from parents who really only wanted a boy. When I was born I was very dark, with ‘sticking up’ hair and my mother (a total blond) somewhat aghast, called me Tiddly Tonky. My eldest sister was known as Wimpy and my second sister Pepita (a mistake by my mother. She meant it to be Perdita) was called Pippity-Poppity-Poo, or Poo - though luckily that didn’t stick - and we once had a budgie called ‘Shivermetimbers’. It was all my mother’s doing; she was very creative with names! It wasn’t that Tonks was a pet name that stuck – it is simply my name’.

What for you is the core of nursing?

I always hope my students will see it as the caring understanding of each individual’s unique human response to the experience of illness (and health of course). Others would say communication – the heart of nursing. I would also add knowledge, always knowledge.

What achievements are you most proud of?

I am delighted by the professorship, and what I hope I can do with it, in a small way, as a catalyst for student learning. Also, Nursing Practice, the three editions of the book I co-edited with Margaret Alexander and Phil Runciman. (note: Nursing Practice was the first UK core textbook for adult nursing. The first edition was published in 1994. Grateful students refer to it as ‘The Bible’)

Who inspires you?

So many! My co-editors of Nursing Practice were, and continue to be, a great inspiration - Margaret for her energy and endless enthusiasm and Phil for her gentle ways and affirming understanding. Both are perfectionists. Also Annie Altschul, who was the nearest I had to a mentor (though she never called herself that) when I first started at the University of Edinburgh and who encouraged me to do my Masters in Nursing Education. I admired her capacity to be quite heretical at times in a way that only someone as respected as she was, could be; and of course all the wonderful students who go out into the world. So often when I write to them I find myself saying ‘…so proud of you’. They are an inspiration.  The patients also constantly inspire me with their courage and endurance and, again, my mother who taught me the value of resilience in the tough times and a little of how to ‘dare to be different’ - and to smile.

Which words or phrases do you overuse?

Gosh, probably too many. ‘We’ll get there’ a phrase so commonly said between nurses on particularly challenging days.  I give students lots of little phrases that I hope they will hold their heads like ‘Asepsis, Safety and Comfort’ –three all embracing principles of patient care and my three ‘Cs’ of bedside documentation – comprehensive, concise and (always)caring. And when the students first go on the wards and are nervous and a little unsure what to do, when everyone around seemed to be so confidently busy. I say, ‘Wash your hands, smile and circle the ward. Someone will need you’ Perhaps now I would be more likely also to add… find your wonderful mentor.

What was your first nurse uniform?

I first nursed on the degree course at St. Bartholomew’s Hospital (Barts) in London and the City University. My uniform had a wonderful cap, created from a large starched white square, an equally starched white apron, tight belt and detached collar with a brass stud that left a mark like a tracheostomy on your neck. I was smallish, and felt like I had been wrapped in a stiff white tube, but it really did give you a sense of yourself as a nurse and it somehow brought about a sense of mutual professional respect. The current universal uniforms, though necessarily serviceable, cannot have that ‘feel’.

Tonks (back row, centre) as a young nurse at Barts

Tell me one story from your nursing that sticks with you.

There are so many but probably one that has stayed with me from my earliest days as a qualified nurse at Barts was the day of the Moorgate tube disaster, when an underground train crashed into Moorgate station. I ‘grew up’ that day. I had only been a staff nurse for less than eight weeks, and at 8a.m. was preparing patients for surgery. The phone rang and the nursing officer (as they were called at that time) said ‘Are you ready to receive the disaster victims?’  Within two hours the whole ward had been re-organised. I saw the very best in people that day. Everyone pulled together, the nursing officers relinquishing administration priorities and literally ‘rolling up their sleeves’. One of our ‘firm’ surgeons particularly comes to mind, working in the darkness of the disaster tunnel to amputate a trapped woman’s foot. As well as the horror, it brought out amazing capacities in people. There was one young woman, a social worker, who had been badly crushed. We cared for her for six months but, in the end, could not save her. 
We can do so much more now.

Gladys Msiska - Nursing in Malawi

‘Nurses witness patients dying for lack of drugs and there is nothing they can do.”

I first met Gladys Msiska at a postgraduate conference where she presented findings from her doctoral research into nurse training in Malawi. Her research had uncovered a difficult truth – that many nurses in Malawi were suffering from extreme burnout to the extent that they were insensitive or even verbally abusive to their patients. I was struck by her passionate clarity and her determination to address the situation. Afterwards, I asked Gladys if she would tell me more about her work for this blog, and although she was leaving for Malawi that week, we managed to fit in an hour to talk.

Gladys Msiska

The working environment for nurses in the small African country is extremely challenging – there is a vacancy rate of up to 77% in the profession, a legacy of nurses being recruited from Malawi in the last decade by countries that could offer better wages and conditions. 80% of these emigrating health workers went to the UK, and in 2007, it was estimated by the Guardian that there were more Malawian nurses in Britain than in Malawi. The results of the shortage are that 24-hour shifts are common and nurses can be left alone to tend a ward of up to forty patients.

Recent efforts have largely succeeded in halting the brain drain, but Gladys says that she herself might have been tempted to come to work in Britain, had she not had a post lecturing at Kamuzu College of Nursing. Teaching had been Gladys’ first choice of profession, but she had been selected for nurse training after leaving school, and practiced in rural clinics and health centres before merging her interests by becoming a lecturer and trainer of nurses.

In addition to staff shortages, recent cuts in aid due to political tensions have led to a scarcity of drugs and medical equipment. ‘Nurses witness patients dying for lack of drugs. There is nothing they can do.’ She describes the occasions where patients have been verbally abused as ‘manifestations of tension and frustration.’ While nurses in training do find some nurses they can look up to and emulate, 'They know the image of nursing in Malawi has been tarnished, and they are sensitive.’

Nursing Students

Gladys was concerned that the training of nurses in the country, especially of the enrolled nurses who make up a large part of the workforce, was task-based, and had no component that dealt with ethics or self-reflection. Says Gladys, ‘They are dealing with people, with suffering others. Nobody chooses to be sick. The world of a patient is a world characterized by fear and anxiety, and you don’t want to increase their apprehension through how you treat them.’

Gladys is devising a pilot programme to train nurses in these issues, and challenge the way that nursing is commonly practiced. In the future she hopes it will extend to all health professionals, creating a more patient-centred approach to care. She is full of  plans for new teaching materials and workshops. It is a time of both turbulence and optimism in Malawi, as new president Joyce Banda brings hopes of better international relations and with that, an improved economic situation.

Yet in the very week that Gladys returned to her country, the Malawi Nation newspaper carried a story of a nurse who beat a complaining patient with a metal bar before being restrained by fellow staff. The nurse was swiftly suspended by her professional body, but it is hard not to think of the challenge ahead for Gladys as a daunting one, but never more urgent.

‘I’m just trusting that things will work out well, ’ she said as we parted.

Kamuzu College of Nursing, Malawi