Detective Writingale

What’s the difference between a nurse and a Police Chief Inspector? Nothing it seems, apart from approximately 30,000 quid a year that is!

Today I learnt that part of the extremely varied skill set required of a good all-round nurse is the ability to dig and dig and dig until the truth be found – even if the truth is hard to hear.

How so? Let me tell you… 

I arrived at Sunshine Nursing Home this morning with a spring in my step and a song in my heart. My nursing career and my passion for it had taken a heavy blow or two over the last couple of weeks but the manager and I had drawn a line in the sand after the medication error recently and I felt positive and vibrant. 

Optimism will be the death of me! 

My shift started out relatively routinely. I made sure all my patients were okay. I spent a while ‘persuading’ the GP secretary that my opinion about a patient who needed to be seen by the doctor trumped hers. I cracked out the medication round accurately and in record time and finally managed to start working my way through the nursing tasks in the daily diary. There was about a week’s worth, all of which had been put off and handed over repeatedly. 

So Mrs B was due her dressing change. I got all her dressings together and grabbed her wound care plan to see if anything had been updated since I had changed it on my last visit. 

And that’s where routine normality ended for me today. The last entry in the wound care plan was mine, over a week ago, and the plan clearly stated it should have been done since then. Maybe it had been redressed and the nurse simply forgot to document it in the separate wound care plan, it is easily done, but still feeling slightly annoyed I went to check on Mrs B and redress her wound. 

As I peeled back the old dressing a smell that was totally indescribable invaded my nostrils and imprinted itself on my brain. It was like nothing I had ever smelt before – and I knew that my day was about to hit rock bottom. Unfortunately for Mrs B, hers already had and I just couldn’t begin to imagine the day she was having. 

The sight that was presented to me brought tears to my eyes and a lump to my throat (not just because of the smell). I’d dressed this very pressure ulcer myself and it was healing; now it was a festering hole– black and necrotic with an odour that could strip paint. What the hell had happened? 

Even if the other nurses hadn’t dressed it in the week I hadn’t been in, the wound should not have deteriorated so quickly. 

I got to work; cleansing, photographing and ensuring an absolutely meticulous aseptic technique as I redressed the wound. I called the Manager in to have a look at it before I
replaced the dressing and gave her chapter and verse as to my actions and concerns. She told me we would have to go down the safeguarding route, notify the CQC and also contact the GP for further advice and possible antibiotics. She also said we needed to complete a root cause analysis of the rapid deterioration. 

And that’s when I turned into a Detective. 

I honestly could have wiped the floor with Poirot or Miss Marple. I analysed every single piece of documentation to do with that wound. There was nothing in the daily notes to indicate the dressing had been changed since I did it last, so that was an issue, but not one that would cause this on its own. There were re-positioning charts to look at and the timing of turns over the past few days, her food and fluid charts to see if her diet had been poor and documentation for a number of other factors that could have affected her wound healing. I checked the mattress setting records and checked that they were correct for her weight. I scrutinised the ‘before’ and ‘after’ photos, to see if there had been any clues that the breakdown was imminent. I spoke to the GP over the phone about a possible infection with the smell and the presentation of the wound. I did a swab and managed to get that sent off to the laboratory for analysis before the cut off point for the day. I even completed the Section 42 safeguarding form and prepared the CQC notification ready for checking; and then took all of my findings to the manager to discuss. 

She listened patiently and nodded when I told her that, according to the notes and the turn charts Mrs B had been left sitting up in bed for most of the night after her tea two nights ago; and because of staffing issues in the home the carers had had difficulty attending to her continence needs that night too. The fact that the notes the next morning stated she had been soiled, wet and changed meant she had probably been left in a soiled bed. This was a probable cause for the infection that her wound now most likely had. She’d then been upset about this the following morning, so hadn’t had her breakfast and had refused any drinks. So her nutritional status had probably been compromised too. 

I felt so proud of myself for coming to these conclusions and felt fully justified in stating what I thought should be done next to get her wound healing again and to prevent this happening in the future. Then I saw the manager’s face. I can’t quite describe the look on it, but I knew it wasn’t a good one. Then she said ‘And what have you forgotten in all this Nurse Nightingale?’. 

I didn’t look much like a detective at that point with that gormless, mouth-open look adorning my face – I didn’t have a clue what I had missed and I shook my head like a dithering idiot. 

‘You’ve forgotten there is a person involved in all this. I have just been up to see her and you have forgotten a person who is in excruciating pain, who can’t see what is happening to her body. A person who you didn’t give her PRN pain relief to this morning before you poked and prodded in her body and who you didn’t see crying silently after you left the room. You’ve done an excellent job in finding the cause of the deterioration but you have forgotten the most basic of nursing skills – empathy, compassion and care.’

Talk about a body blow. Had I considered Mrs B and how she felt? How frightened she  
must have been when she heard me talking about the necrotic black hole in her backside. How agonising it must have been for her when I was firking about in the wound like I was digging for gold. Clearly not enough. All through this, she maintained her own dignity; she didn’t cry out and she didn’t tell me to stop, she simply cried silently. 

I left the office in silence. I went straight to Mrs B and apologised profusely. I don’t know who cried harder, me or her and in the end she wrapped her good arm around me and told me not to worry. 

I looked up and the Manager was at the door. She gave me a sad smile before she walked away, shutting the door behind her. 

A nurse’s role means wearing many hats. Today I forgot the most important hat of all, and that was my human being hat. As important as the clinical diagnosis and treatment of the wounds, diseases and illnesses we come across is, we can never forget there is a caring aspect to our role too. I don’t think I ever will again! 

Detective Nightingale? I think not. Reflective Nightingale is who I am today.