Enough Is Enough: knowing when to stop

Look at the photo above. Isn't it a beautiful view? I took it last week, during a walk with my two children. We were planning to go to Old Harry, on the Jurassic coast, then head into Studland to catch the bus back home.

We packed a picnic, lots of water (but as it turned out, not enough), a camera, and our sense of adventure. Seemingly intact, we left home and made our way along the beach.

We hadn't even made it to the bottom of the road before my 11 year-old daughter began to complain. Actually, we had had a morning of everything being not quite right in my daughter's world. I had tried to enter into her space, to try to help lift her out of her sense of irritation and negativity. She didn't want to invite me in, though, so she remained where she was, and I hovered around the outside, hoping for a free pass, or at least the offer of connection.

I kept things upbeat: "what a beautiful day it is!" (it is the SATs season: both children are sitting them this term and so I can almost confidently assume I have learned to use the recently-controversial SpAG exclamation mark correctly) I repeated, smiling, nudging and hugging both children. "We are so lucky to live here. Let's enjoy the day". My remarks were met with "I'm hungry and thirsty. When can we stop to eat?" We had only just left home, being fully watered before we set foot out of the door.
We decided to stop after we had walked for half an hour. In that time, we made one toilet stop, a water bottle refill, a rucksack adjustment and two shoe-lace re-ties, scattered with cries of "I'm hungry!", "My feet hurt" (what, already?), "When can we stop?" and "My eyes hurt". I confess that I uttered at least two of these statements. My 7-year-old was buying into the sense of adventure, but my 11 year-old was still in her own space, to which we were neither invited to join nor a party to, but rather the sounding boards for her irritation.

We enjoyed our lunch whilst admiring the view overlooking Swanage bay, on a bench which seemed to have jumped forward a few feet since we had last visited it; actually it was due to cliff erosion which had reduced the distance between the bench and the cliff edge. We had a lovely lunch, the mood lifted and we joked about being "hangry".

After a while we continued on the path up towards the top of the hills. Things were going well until my daughter felt she couldn't continue up the steep steps. I patiently encouraged her to carry on, one step at a time, but after another 10 minutes of complaining, bickering with her brother and getting cross with the steps, I felt it was time to stop. I tried to explain that it was OK to find it difficult...that not everything is easy nor intended to be, that the pain and difficulty we can experience can often end up giving us a completely new view and experience. After another round of sibling conflict I decided that enough was enough, so we turned round and walked back down the hill.

The lessons for me?
I have learnt that sometimes, it's easier to quit whilst I'm ahead. I learnt that the view we had on the midway point of the big scary hill will still be there to re-visit another day. Some days are meant for just climbing half-way up the hill, which is the successful point - that getting to the top of the hill isn't always the indicator of success.

I have learnt that my daughter was able to articulate her feelings because she felt safe and listened to, and because she is strong-willed in her own ways, which I am honour-bound as a parent and as a woman to listen to and respect. She is strong, fit, healthy and persistent: so the fact that she was telling me she couldn't do this walk to the top of the hill and beyond was an indicator of her own strength in admitting to herself and to the world outside her own space that "enough is enough".
I have learnt that my own projection of failure to meet my goal for the day (to get to Old Harry, walk into Studland and catch the bus home) to my children is not helpful for them or for anyone; and I have also learnt that I too felt that "enough is enough" when I caught myself spiralling into negative self-talk and buying into the cortisol-adrenalin mix that was swirling around me in the past week or so prior to this walk.

The view: oh what a beautiful view! The ability to see with clarity, to understand and gain an alternative vista had lifted me out of my head and into a beautiful possibility to turn things around from a negative into a positive.

To know is to understand, but to feel is to reach within the depths of empathy, compassion and sample the richness of experience from a higher perspective.

If we can accept that there is not always a right answer, a right way to do something, that things can go wrong; if we give ourselves permission to make the mistakes, then we can learn something beautiful from them.

The Mindful Nurse

It is 5.30pm on the last Friday in January. I am driving through heavy rain, the velvety darkness looming ever closer as I edge my way through rush-hour traffic to get to work, 26 miles from home. Storm Gertrude is fully embracing the thrill of the moment, her blustery vengeance rocking my car along the bypass. As I arrive at work and walk to the entrance, I am peppered with hard rain, so that by the time I get into the hospital corridor, my face and head are wet; the contrast of the dry, warm air is like standing in front of a recently-used, warm oven, devoid of a freshly-baked cake that was there before: slightly comforting yet tinged with melancholy, as I remember it's a Friday night and I am at work instead of spending time with my children.
As a bank nurse, I am employed by the NHS trust I work for, but don't have a permanent contract. I choose to work on the bank because it suits my life as a single parent. There is only so much help I can comfortably ask for, and I feel that I should be present in my children's lives as much as I can be. It also slots into my commitments to running my business as a mindfulness tutor. But I do miss being a part of a team, and I miss being given the responsibilities I used to have.
Tonight, I am assigned to work in the Emergency Department (ED), where I work regularly, and somewhere I enjoy. It is the busiest, most intense place to be at times; very fast-paced, with anything and everything coming through the doors at all times of the day.
I scamper to the canteen to grab a sandwich, eating it quickly on my way back to the ED, as I have only 5 minutes before I start work. At 6 pm I walk into the department and see the queue of patients on trolleys, waiting to be handed from paramedic to the hospital. There are no beds to assign them to at the moment, as the wards are waiting to discharge patients or wait for clinical decisions to be made. The nursing and medical staff are busy; very few have had time for a break. I am asked to go to help out in "minors", where people who self-refer come to be seen, and where the GP referrals come in to be assessed or assigned speciality beds.
This area has been short-staffed all day, so there is only one nurse triaging and handling the GP referrals. I am given a list of patients to get to ward beds as soon as possible, in order to free up cubicles for the other patients coming in through the doors.
I spend an hour or so transferring patients to wards, handing over to a wide stress-spectrum of staff. All of them are tired, busy, hungry, some are finding it more difficult to hide than others. I then return to the ED to help with triage.
A couple of hours later I am asked to perform a procedure I have been trained to do but haven't done for a year or so. I feel slightly under-confident but fairly sure I can remember how to do it. I begin well, and then I feel the doubts creeping in. My stomach tightens and my confidence wavers. Having already talked it through with a senior colleague, I then ask her to come to supervise me. She takes over, doing the procedure exactly as I would have done it. I feel stupid. Why didn't I believe in myself? I try to explain this, but it's too busy, and the colleague is also due to finish her shift. My feelings of stupidity continue to niggle away at me for the rest of the shift.
4 and a half hours later, I head to the staff room for a 20 minute break. I sit alone, half-aware of some rubbish on the TV that someone had forgotten to switch off before leaving. I hear the rain and the howling wind outside, I check the time and I feel tinges of emotions coming up. I reflect and ponder on the events of the shift so far, then head back out to carry on. More patients coming in, more to take to wards, more to triage. I try to work as effectively as I can. Stock hasn't been replaced during the shifts due to business, so it means going off to re-stock whilst seeing patients. This slows everything down - especially when I don't know where something is kept, and can't find a member of staff to ask.
My shift is supposed to finish at midnight. At 11.55pm I realise this is unlikely. There is still a fair amount of things that need doing on the patients I have been preparing for the wards and have been clerked by the doctors. They are important things like giving intravenous antibiotics, administering analgesia, performing procedures. My colleague has taken over triaging, and she is busy. It would make things more difficult for her and the patients if I left. I decide to offer to stay for another hour, to try to tie up as many loose ends as I can. My offer is taken up. I spend the next hour getting things as organised as I can, before leaving at 1am. This was a good shift.
My drive home is even more perilous than the journey in, not least because I am feeling tired. I am feeling frustrated, too. I mull over the events of the shift, conversations, reflect on what I could have/should have done, I try to see events from the perspective of the other parties, and conclude that we, as an NHS body, are stressed. We, as an NHS workforce, are at capacity and beyond. We, as people, are not valuing ourselves enough, we are not giving our own self-care, we lack self-compassion, not just individually but as a whole. I know this to be true of me, because my inner monologue on the way home was twenty-five miles of negative self-talk, and one mile of self-appreciation. An unusual ratio for me, as I was holding on to feeling stupid about the failed attempt at the procedure I was asked to do.
We spend so much of our working lives engaged in processes, care, standards and unrealistic, target-driven restraint enforced by madmen in suits, who sit in the upper echelons of political power, exercising what seems to me to be some form of delusional magnanimity whilst bankrupt of integrity. These are the people who are slowly but surely dismantling health care workers like a six year-old plays with Lego characters. Metaphorically speaking, bits fall off, bits get re-attached, torsos and heads are changed about, some are thrown back into the bucket, others are trodden on. Some are super heroes and carry on, intact, others are strong and many are simply doing their job as best they can, coping with whatever comes their way. These nurses I worked with tonight are heroes in their own way, as they are doing their job as best as they can. They are feeling the pressure. I felt sympathy for them; there is so much more good stuff to them. If only they could see that within themselves, too. I try to have sympathy with government and ministers, but I find it difficult.
So as I mindfully work my way through shifts, I remind myself of the importance of making sure I feel a connection with everybody I work with; but I feel such a need to reach out to the staff I work with, teach them mindfulness as a form of self-resilience and in care delivery. I understand. I get it, because I know the anger, the stress, the fatigue, the food and drink-deprived headaches and full bladders and achy legs and backs.
 I love being a nurse, not for the pitfalls - for the privilege - and there are so many.  It's just not always easy to see.

Should Doctors and Nurses Be Compassionate?

This was the question on Radio 4’s programme Beyond Belief, earlier this year. Anna Smajdor, a medical ethics lecturer at the University of East Anglia, put the point across that it is not necessary within the role of the health care professional to provide compassion for their patients. Anna says,

“we find it very difficult to know or control what people are feeling”, explaining that it “would be nice if every time I went to the hospital, the doctor or nurse would love me as much as my mother does, but do I have the right to expect or demand that? I don’t think I do. Compassion is about what people feel for you, and you cannot demand that people provide you with an emotion as part of your due…in the health service I think that’s going too far”

What?!

I couldn’t imagine providing care for my patients without giving compassion. It’s not in my personality to shut off my human side, and I believe that is the case for most people.

Many years ago I looked after a young man who sadly died. He was from another country. His parents, who were acrimoniously separated, were informed just as they boarded the plane to see their son in our hospital, that their only child had died. They had to endure a several-hours flight in the worst of circumstances, to arrive in a country where they could not speak the language, to confirm the identity of their child to the police. To say that this was an horrific experience for anyone was an understatement.

His mother broke down when she saw her son. Her wailing, grief-stricken cries cut deeply into everyone who heard her. Unable to communicate with her, all we could do was offer her our arms and our shoulders to share her anguish, the crevices of our necks warm and wet with grief. This mother and her estranged husband, consumed with grief and the horror of their situation, did the only thing they could in that moment: they lashed out at each other. Even in another language, we could feel the conveyance of hatred, anger, shock and bitterness in their voices. But there was little any of us could do. We didn’t understand what they were saying. As a 23 year-old new-ish nurse, I  lacked the experience to deal with this as a professional, but I felt every ounce of their pain.

Later, as I sat with the mother and father in the relatives room of the mortuary, a police officer asked them a few identifying questions. They were able to answer through an interpreter who we had managed to find, although at the time we could only find an inexperienced nurse on another ward, who was clearly traumatised by the details, because she was getting the full impact of the parents’ grief.

The officer handed the mother a clear plastic bag, containing her son’s large, leather-strapped watch, his wallet with a few foreign notes mingled in with the British £10 notes, and his passport. I felt this to be so impersonal that the property was handed to her in this way. She broke down again as she took the bag from the officer. I saw her son’s passport photo, and I too began to cry. He looked so different in his photograph, so handsome and the same age as my younger brother. It was the most intense, sad and loneliest place I have ever visited as a nurse. Grief following death is an all-consuming, exhaustive and potentially destructive place to be. To professionally help a patient or relative in any situation without the connection of humanity, compassion and care is impossible, in my eyes.

Here is where mindfulness can assist the professional in dealing with these kinds of situations. As nurses, we see the most vulnerable people deal with the most challenging of situations in the strongest ways they know how. We support them through these experiences in the most sensitive, compassionate manner and with fortitude, in the ways we are taught, the ways we are shown, and in the ways we would want to be treated if we were ever to find ourselves in the similar circumstances we are exposed to in our work. This is the key to being able to do our job. I know that on days when I have been rushed off my feet, when help is thin on the ground and I haven’t been able to give my best care to my patients, I go home feeling that I have failed to do my job effectively, and I know many friends and colleagues who feel the same. But mindfully working through these situations, by making that meaningful connection with patients and their relatives can make a big difference both in the delivery of care and the way the healthcare professional feels when they leave work.

It is okay to empathise with the relative about how difficult they are finding their grief.  “I know how hard you are finding this, and I feel how overwhelmed you are, this is tough but I am here to help you.”  Sometimes it’s not about finding the most effective way to provide care, but it is about making the emotional connection in a mindful way.

As I said goodbye to the mother and father of the chap I had cared for, all I could do to convey my empathy to them was to place one hand on my heart, and hold the mother’s hand, with the other. I know we couldn’t verbally communicate, but I know that she felt what I meant, and I felt the understanding between us. I hope that my compassion was felt and understood. The health service is made whole by compassion, and to deny anybody that in their time of need would be to deny their humanity.

The Code

Earlier this year,  new changes were made to The Code for nurses and midwives. The Nursing and Midwifery Council (NMC) has set updated standards that all registered nurses and midwives must apply to their practice.

There has been mixed discussion today from healthcare professionals and from the public, some of whom are in favour of the updated code of conduct and revalidation process; others who believe it to be somewhat condescending towards nurses and midwives. After the Francis Report and the Keogh Report highlighting flaws, concerns, dangers and poor practice across poorly-performing trusts, I find it puzzling that there is so much variation in care delivery across what should be a well-performing, unified organisation, theNational Health Service. Will updating a code of conduct for some of its workforce be enough to drive up standards of care delivery, or is there Something Missing?

I’ve worked in several different trusts as a nurse – both in primary care and secondary care – as well as in the independent sector for a while. Wherever I have worked, there have always been various issues ranging from money shortages, poor standards of care, mistakes, anger and disenchantment, to job dissatisfaction and stress with burnout. I’ve seen the best and the worst of care; with some incredible, caring staff who will go the extra mile for their patients. I’ve heard people say that the NHS runs on the goodwill of those who work within it. I’ve always done my best as a nurse to work to the best of my ability, for the benefit of patients. And if you were to ask any other nurse or midwife or healthcare worker, they would almost always say the same.

I have always said that if I ever stopped caring about my job or my patient, it was either time to change job or leave nursing. I often wonder if standards of care delivered by the NHS workforce reflect the standards of care delivered by the trusts and by the government…if as healthcare professionals we are expected to uphold standards and codes; if NHS Trusts are expected to comply with statutory regulations, targets and standards; what targets, standards and compliance are in place for the top governing bodies and government which control the NHS from the top down? Where does this drive for improvement, delivering high standards of care, behave compassionately and respectfully to the patients begin – the individual, the government – or both? Where does it begin for the staff? Why are staff bullied? Why are there failures in care? Will a code of conduct be enough to ensure that dreadful things don’t happen in the NHS, any more, or is there Something Missing?

I believe there is: one of the fundamental elements of mindfulness practice is based on connection. Connection with the Self. This connection, in the form of reflection or a moment to sit still and contemplate a situation or event that has taken place allows a more meaningful experience. Regular mindfulness practice and other forms of meditation, such as Metta meditation has a positive impact on ourselves: it makes us “nicer”. This connection within, when practiced regularly, can enable us to connect, empathise and act with compassion towards others. I would like to see this connection embedded with everyone, including patients, staff, trust boards, local and national government. The connection works both ways, though – even I struggle with that bit – I find it difficult to have compassion for the current political mess the NHS is faced with, at the moment.

So, this new code…I hear (and connect with) all those who have positive and negative experiences in their care delivery or as a patient; I understand and agree with much of the revised code; but  I also see that mindfulness deserves a high profile space in clinical care, starting with training student healthcare professionals. Influencing our thoughts towards ourselves and how we relate to others begins within. If this happens, who knows: perhaps others will begin to be influenced positively, too – including the public having a greater sense of trust and empathy for what NHS staff face on a daily basis.

Nikki teaches mindfulness and meditation to adults and children, and works as a nurse in an acute NHS hospital.

The Mindfulness of Love

This post encourages you to ask yourself what love, in its implicit sense, means to you. Can love be implicit, or is it more fragmented, than that?

Suppose I declare: “I love chocolate”. But when I really think about it, it isn’t the chocolate I love: it’s the sugar rush I experience whilst eating it. It’s the moment I allow myself to sit quietly and relax whilst I am enjoying the sugar rush. It’s the reward I give myself, like I’ve given myself that permission to enjoy the chocolate. It isn’t the chocolate itself. This might be a different experience to the next person, but it is my perspective.

So do I love chocolate? Maybe; but not as much as I love listening to the radio on my way to work. But when I think about it, it isn’t the person on the radio or the music that I love, it’s the act of driving and being quiet that I love. It’s the time spent alone with my thoughts, peppered with music and conversation that I love.

So, do I love listening to the radio? Maybe; but not as much as I love running. I LOVE running. I have to run to feel human, again. Running gives me headspace, time to meditate, time to listen to the radio (and sometimes reward myself with a little chocolate, afterwards). Running makes me feel happy and relaxed.

Yes, I love running. But I love nursing, too: I love coming to work. Seriously, I do. It helps me forget about any negative stuff going on in my life; I get to meet all sorts of different people from all walks of life; to me, nursing is an art where it is a constant project of learning to understand others, help alleviate symptoms or pain, help to make someone better, as well as have the privilege of sharing some of the most personal experiences of someone’s life, with joy, happiness or sadness and grief. There is little in life more rewarding than seeing someone come into hospital ill and in need of help, and leave with a smile on their face, fit and ready to carry on with their life. It is the same with my reiki and my mindfulness work. I feel such gratitude and love for the work I am lucky enough to do – and be paid to do it!

I love my children. They are the biggest, most love-inducing, intoxicating part of my life. I live and breathe for them. I will walk to the ends of the earth and back for them. Who wouldn’t do the same for their own children? My children are funny, silly, clever, annoying, talented, argumentative and unconditionally loving towards me. No matter what mood I’m in, they can snap me into a smile just by the things they say or do. Their hugs, our chats, the singing and dancing, their little notes telling me “I love you” or  their paintings and drawings show me that I am so lucky to have them in my life. They love life from moment to moment and at full speed. My family and friends carry the same significance to me.

And finally, I love myself. There is nothing wrong with saying this. In fact it is crucial for the rest to fall into place. If I didn’t, I couldn’t enjoy and treasure everything that is my life. My life is made up of these loves and joys. If it wasn’t, I couldn’t be happy. If I didn’t love myself, I couldn’t love my life the way I do. I have my off days, I have the days when I have to search a bit deeper to find that love and joy, but it is always there. I believe that without that love for myself, other aspects in my life carry less meaning. I nurture myself and  others. It’s what I do. Nurturing the love within means that everything else can grow, too.

The Seventh 'C'

The more I embed my use of mindfulness into my nursing care, the more strongly I feel about how important it is that as nurses, we make a meaningful connection with our patients.

I started nursing back in 1993. I took a gap year before starting my training, to work in a nursing home. I wanted to develop my basic nursing skills, to begin to learn the art and science of being a nurse.

To me, nursing was about caring. I wanted to care for people. I wanted to make my patients comfortable. I wanted to understand what they were experiencing, as well as empathise with them. I wanted to know everything. I was an eager beaver, keen to do the best I could, but was still very wet behind the ears, completely naive, but full of enthusiasm.

Working in the nursing home was a shocking experience. Standards were poor: the home smelt awful. The residents were not properly looked after, but although I knew at the time the things I was witnessing was wrong, I did not know what to do about it. The company I worked for didn't pay us on time each month (once they arrived at the home to pay us by cheque at 5pm on Christmas eve); they didn't pay the bills on time, so at one point the phone line was disconnected and if we needed to make a call one of us had to leave the home and run 5 minutes up the road to the nearest phone box. The bill for incontinence pads was left unpaid for months, so the new orders were not delivered. We were told to cut up towels to use as pads, or dry the used incontinence pads on the radiators. No wonder the place smelled. No wonder, either, that most of the poor resident's pressure areas were breaking down. I, along with some others, refused to do either of these things, much to the chagrin of the company director.

It was a diabolical place to live and work. Most of the care staff did care about the residents, and wanted to make a real difference. We all knew of each individual resident's likes and dislikes (Betty loves cheese sandwiches, but Ethel hates cheese; Sam likes to listen to classical music in the morning with his porridge but Mabel prefers silence to eat hers; Rose always has to sit by the window, to see who is coming in and out of the front door - but everyone of us knew that she sat there each day in the hope that she would see her family walk into the home to visit her - but tragically, that event only took place a couple of times each year; partially-sighted Anne has to have her clothes laid out in a certain way each evening, so that she could find them in the morning). We all knew the routines and we followed them as much as we could, each day. But this did not take away from the fact that dreadful things were going on in that home, things that I could not bear to see. I felt a real connection with the residents, and that was the thread that weaved in the compassion, the care, the (attempted) competence, and the commitment, which led to the courage to communicate the terrible goings on to the authorities.
It was the connection with one or two in particular, that led me to write poems about the struggling, elderly bodies that tortured their fiery minds each day. One lady, on waking each day, would cry, because each night she prayed that she would die, rather than wake in pain each morning, her arthritic joints agonisingly taunting her heart, which longed to walk hand in hand with her husband on the beach, or hug the grandchildren she loved, who smiled at her from their gilded frames on the windowsill. I would try to be in her room before the others, to help her get dressed. Why? Because she insisted on wearing her tight-fitting satin blouses each day, which were almost impossible to bring her tense, creaking arms through. But I had found a way of being able to do so, unlike some of the other staff, who would take out their annoyance of the perceived inconvenience as they wrestled and tugged at the poor lady's arms, roughly pulling and tutting as she winced and cried out in pain. I couldn't bear to see it, so would try to get to her room first and gently, slowly ease her arms out as straight as I could, one at a time, apologising repeatedly, but knowing that the smart, pink blouse the lady wanted to wear, along with her matching lipstick, would make her feel just a little bit better about being alive, a little bit more "in the pink" than she really felt: quite simply, it made her feel human.
In the end, a good year or so after I left and started my training, the home was closed down after several serious complaints from relatives. There were staff there who were deeply caring and concerned about the treatment of the residents, as well as the living conditions and the mismanagement of the company (who subsequently found themselves in the position of being broke, forcing the closure of the other homes they owned, too), but 22 years later, I am still very saddened by the thoughts of the events I witnessed. I wish I could have done more to change the circumstances. I wish I could have stood up to the company and banged my drum louder for more to hear, so that changes could have been made. But I was green, I was naive, and I didn't know what I needed to do to make things better.
Ironically, when I started my training at a London teaching hospital, it was comparative luxury to be able to walk to the cupboard when I needed soap, incontinence pad, sheets or clothing, to see shelves full of everything I needed to be able to provide the basic nursing care required. It was bizarre to me that NHS staff were complaining of a shortage of equipment and resources. On reflection, it showed me just how bad things were at the nursing home I worked in.
On my first night in my nurses digs, I put up the poems I had written about the residents I had looked after on the wall next to my door. I read them each day, to remind me of the sorrow and pain these folks had suffered, in order to do the best for my patients. These and many, many more patients over the years are the connection within me to each one of those I have seen suffering, in pain or anguish, in fear or terror. The connection of human spirit within the nurse and patient relationship is what weaves the sometimes achingly beautiful compassion, care, courage and commitment into the art of nursing. Connection is the thread that holds everything else together. Without connection, the most basic, yet most complex circumstance is flawed.

So, 22 years later, I am no longer green or wet around the edges. I still love my job. I still make mistakes, each one leaving its mark for me to learn from and grow. I have seen so much heartache and pain, like other clinical staff; I have seen miracles, I have seen the fragility of the tiniest life to the vulnerability of the mightiest of men, anguish and grief in many; and joy, pride and acceptance in those too numerous to count.

But now is different. Now I am using my skills in mindfulness to help my patients across a wide spectrum of age, illness and diseases. I am discovering how best to use the connection I can make with my patients, to help them connect with themselves to understand that they can help to ease their discomfort. I am seeing results, sometimes instantly, just with a tweak to the way I work with each individual. So in my clinical practice the six 'C's have another recruit. Who wants to connect with me?