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Senior Lecturer Pens Moving Account of Day on a COVID-19 Ward

Denisse Levermore, who lectures on the University’s Child and Adolescent Mental Health degree, wrote this piece as part of her own well-being, but also to share with students in future.

“I wrote the diary piece to try to capture the day to day role of a nurse on an acute ward alongside the ongoing impact of Covid-19 on staff and patients,” she said. “The ‘new norm’ being vastly different from the ‘old norm’ felt important to reflect on for my students, my colleagues and I, and I tried to write it in an accessible format for that reason really. It also felt an appropriate way of managing and supporting my own feelings in relation to the intense nature of the work that a nurse undertakes and to reflect on the complex skill set required to manage very difficult and emotional situations that are sometimes very difficult to talk about.”

Reflections of being a Staff nurse on the front line – NHS Acute Covid-19 ward

7.30am – start of 12 hour shift, get to the hospital at 7am to get changed into theatre scrubs to try to avoid the possibility of taking any infection home. Every other nurse and health care assistant on the ward also doing the same therefore 9 people waiting to get in a small changing room/toilet to get changed (takes a while).

7.30am – handover – night staff take us through the patients; any changes and plans for their care – every patient is Covid-19 positive (or negative but has symptoms that are significant therefore treated as positive). Covid-19 swabs have approx. 70% reliability therefore a lot come back with a false negative result; mainly due to error in taking the swab. I have taken a Covid swab before and it is not pleasant – 2 long swabs (one in each nostril) right up as far as you can go with a good twizzle then 2 more long swabs down the throat – back as far as you can go until the patient has a gag reflex, the last patient I did this with told me to f*** off and tried to bat me away and do you know what, I understand why!

8.00am- finish handover, collect my visor for the day and write my name on it – 1 visor for 1 shift, wipe visor down with Tristel spray (highly effective disinfectant) between each patient contact. The new norm is PPE consisting of plastic apron, gloves, face mask and visor, these take time to put on and take off, alongside 2 episodes of washing your hands (within NHS guidelines). Sister asks what I would like to order for my breakfast – charities and local business have donated food to ‘feed the NHS front line’ so we have breakfast, lunch and supper now provided, with drinks – I have never ever known this in 30 years of working in the NHS. I order a sausage sandwich, sadly by the time I get to my break at 11.45am someone has eaten it……………..so I have a bacon one instead.

8.05am – new admission, very poorly, one of my allocated patients and potentially Covid-19, but with lots of underlying complications – have to prioritise care and this patient is first on my list to ensure admission and care is sorted, but I have 6 other poorly patients too (the new norm with Covid-19 is also ‘very poorly’).

8.15am – Working with a very experienced Health Care Assistant (worth her weight in gold) and a third year Medical Student (very keen and lovely) who is working on the wards supporting the nursing team, we have 7 very poorly patients to look after between us. 3 of these patients are on high volume oxygen. As a staff nurse ultimately these 7 patients are my responsibility so the need to know exactly what is going on with their health and care is crucial as this could change in minutes (and does) therefore communication between your team is really really important.

8.30am –I am in with new admission; concerned about blood glucose level, patient is diabetic (blood glucose currently 27 but should be between 4-7 mmols), checked blood ketones level (4.8 but should be under 0.6), so ask Doctor to urgently review as patient is keto-acidotic (life threatening condition). Due to Covid-19 each ward now has a Doctor based on the ward – previously you would need to bleep them or put a task online, so the response now is virtually instant and you get to know your Doctor on your ward – first name basis, wonderful.

8.45am – I check medications/insulin to give whilst Healthcare Assistants give out patient’s breakfasts. Breakfasts all in disposable cardboard tubs/trays with disposable cutlery – very unappealing and hard for some patients to manage. Medications are now all online so requires logging in and takes an age sometimes to synch your Smartcard and gain access but better than paper charts ultimately. Cannot take drugs trolley into bays due to infection control so have to try to take medications in on a tray with names/numbers etc as a job lot to minimise my exposure to Covid-19, as you need to gown up and take off PPE(alongside x2 lots of washing hands and spraying visor) each time you enter a side room or bay (donning and doffing as it is called in the business…).

9.15 – 11.45am – asked by Medical student and HCA to check a patient’s skin – need to grade pressure sores according to chart, put any dressings needed on pressure sores, order air mattress – refer to Tissue Viability team, ensure all this is handed over to Sister and next shift. Cleaner tells me another patient in a side room needs the toilet – cleaner has just cleaned the floor (it’s slippy), patient is desperate. Have to don PPE double quick time to support patient – how easy would it be to just nip in without PPE but have to put the need to protect my health first meanwhile telling patient very loudly through the window that I am coming. I support others in assisting patients with washes. We try to minimise patient contact to avoid viral load/exposure to Covid-19 as much as we can, most patients need ‘all care’ so how is this possible???………

Trying to reduce volumes of oxygen with patients but there is a fine balance in doing this, reduce by too much and oxygen levels in the body can become dangerously low; keep the oxygen too high and how will we know if patient is improving and high doses of oxygen can also be harmful in some situations – it is my role to judge this. Also my role to judge whether patient can maintain oxygen levels in the blood (oxygen saturations) via nasal specs (a tube with 2 prongs up each nostril delivering oxygen) rather than a mask (higher concentration of oxygen via a mask). I judge one patient is ready for nasal specs and all goes ok – patient can eat and communicate with these on, so much better all round. I judge my new admission can have a simple oxygen mask rather than a non-rebreathe mask (non-rebreathe delivers very high flow oxygen 60-80% so better to have lower percentage if patient can manage); patient manages. We measure this by taking oxygen saturation levels on a little machine that fits onto the patients finger – oxygen levels should be high 90’s – 100%, my patients are 88% in 10 litres of oxygen via a mask (the patient does have an underlying medical condition (COPD, Chronic Obstructive Pulmonary Disease) so lower oxygen saturations are expected but this is with high dose oxygen so still concerning – keep monitoring. With Covid-19 I have learnt more about body oxygen requirements, controls, masks, dosages than ever before.

11.45 –much needed break, bacon sandwich (meant to be sausage….) in staff room – cannot leave the ward at all due to Covid-19 infection control policy.

12.15 – 2.00pm – Dinners for patients (cardboard trays, plastic cutlery…..). Medication round with intravenous drugs (most patients on intravenous medication – usually anti-biotics; given via a needle (cannula) in the patient’s vein). One patient has accidentally knocked his out, Medical student offers to cannulate but this patient is very difficult to cannulate so we ask Doctor (nurses can do this but I need more training to do this as don’t do it regularly enough, and not sure I want to do it to be honest..). All IV drugs up and running. Ensure all patients charts are up to date, my team let me know patient’s vital signs (observations). Worried about another patient (high temperature, raised heart rate, fast respirations, low Blood pressure) National Early Warning Signs (NEWS) score is very high (this scoring chart gives us a way to score any concerns and enhances decision making) – I let Doctor know patient needs reviewing urgently.

2.00 – 5.00pm – Write up all patients notes from the morning – it is my responsibility to maintain professional notes on all patients, ensuring I adhere to Nursing and Midwifery council guidelines and to ensure the next shift know what is happening. Sister tells me there are changes to be acted on for my patients (Doctors, Sister and Discharge co-ordinator have decided this); one patient (new admission) is transferring to a respiratory ward; another patient is going to a nursing home; another patient is being transferred into my bay and another of my patients is being transferred to another ward so 4 big changes to do in a short amount of time, as the hospital needs to transfer people into these beds. These changes require booking medications; transport, porters; packing patients belongings up, ensuring patient and relatives know they are being moved and to where; collecting medical notes (making sure they are up to date!) then waiting 30 mins to an hour before rooms can be cleaned (due to Covid-19), booking cleaners to do this. I ensure poorly patients are transported with nurses and oxygen; before Covid-19 patients are transferred to other wards all nurses and patient have to wear a mask and corridors are kept clear. Currently no visitors allowed at all into the hospital, no relatives, we cannot take the ward phone into the rooms due to infection control so this is difficult for all. There is an expected death on the ward, very sad situation and managed by nurses and other health care staff, a constant reminder of the dire situation we are in.

5.00pm – much needed second break, cheese sandwich and snack provided (very much needed), try to sit and read a book to take my mind off difficult and stressful situations but you are still in the staff room so other staff still come in and ask you questions so you are never really away..

5.30 – 7.30pm – Suppers for patients (cardboard trays and plastic cutlery (you know the drill…), my final medication round but with fewer patients as so many changes this evening. One patient remains very poorly, appropriate care given and relatives aware. Checking in with my team throughout the afternoon in relation to patient’s fluid/food intake, urine and bowel actions, NEWS scores, mobilisation and any other notable changes, ensure charts updated.

7.30 – 8.00pm – handover to night shift, important information and changes.

8.00pm – wait with 9 other nursing staff to get changed out of scrubs in the changing room/toilet.. and go home

8.45pm – home, my children direct me (not that I need it ..) straight in the shower to decontaminate further, wash hair and put all clothes in 60 degree wash. They worry I am exposing myself and them to Covid-19 and I understand that fear.

Feelings – absolutely exhausted both mentally and physically, lots of thoughts about patients/care/future going round in my head but remain secure in knowledge that we have all done what we can to treat and help patients to get better and remain comfortable with our professionalism, respect, compassion and the best care we can give whilst doing all I can do to protect myself and my family from Covid-19 exposure. Strange times…

#love the NHS