Following a District Nurse in East London, Summer 2018

It would feel strange to complete an internship at the QNI without gaining an appreciation of the work that Queen’s Nurses do and an understanding of the sort of exemplary service in community nursing that merits the title. To this end, I spent a day shadowing Liz Alderton, a Queen’s Nurse, Team Leader, and district nurse of 28 years.

Liz works in Harold Hill in North East London, not far from Romford. Harold Hill is an area dominated by a sprawling housing development, created to re-house Londoners after the Blitz. Still today, it consists predominantly of social housing and a community of comparatively low socioeconomic status, a demographic which poses specific and endemic health problems. Obesity, addiction, and mental health problems are rife in Harold Hill, all carrying the possibilities and probabilities of complex co-morbidities managed by the integrated community healthcare team.

The first two patients we saw were people with diabetes unable to administer insulin themselves – diabetes being very common in low income communities with a prevalence of obesity. These patients take their insulin with breakfast, so Liz sees them early in the morning, before going into the office at the health centre, and another district nurse sees them for their second shot. The first patient, Arthur*, was an elderly man with learning difficulties.

Arthur was very deaf, so it took a few attempts to properly introduce myself, but he clearly knew Liz well. The visit was quick and routine; a finger prick and an insulin injection, and then we were on to the next house. Irene* was elderly and vision impaired, but was still living independently. While administering the insulin, Liz gave Irene advice about her suspected ear infection; in her visits around the community, Liz often provides advice on a variety of healthcare needs at once, especially in the elderly who may be suffering from multiple ailments alongside complex or chronic needs.

District nurses carry out assessments for patients who require end of life and palliative care, creating a plan of action to provide comfort and pain relief in their final months, weeks, or days. Allowing patients to die at home with their family, but with a high standard of pain relief and palliative medicine, is no small mercy. Though it is a service that many of us have never encountered, it is one that deserves its place in our NHS; the value of a good and comfortable death, for both the patient and their loved ones, cannot be understated.

Such an assessment was planned for our morning together, with a new patient who was about to be discharged from hospital. He required an adapted bed, so that medical care could be provided in his own house, allowing him to die at home. As soon as we were in the office, Liz phoned his wife to check that the bed had arrived and been set up. She introduced herself on the phone, but after a few words from the man’s wife, her tone dropped, and became slow and gentle. The bed had arrived, it transpired, but the patient had died that morning, in hospital.

Liz was keen to take me to visit, in her words, one of her favourite ever patients, Donna*, to view a syringe driver and the role it plays in palliative care. Donna, around 45 years old, was suffering from metastatic cancer, and had been on palliative care for three years, cared for by Liz the whole time. In these three years, they had formed a clear bond. Walking into Donna’s house, it was clear why Liz loved to visit her so much. Liz’s husband Howard* greeted us, and welcomed us into their home warmly and without any pretence.

A connection with family members as well as patients is inevitable in long term care, and Liz told me a story of how Howard had once baked her a pie to take to a family gathering, after she had mentioned it briefly in passing. Meeting Howard and Donna, this didn’t surprise me; they were softly-spoken and always smiling. It was clear that their faith and a relentlessly positive outlook had been enormously beneficial to Donna and her family in coping with her illness. We chatted with Donna about the news, her childhood in the Caribbean, and the pigeons that were trying to nest on her roof.

Then Liz showed me the syringe driver, a great tool in district nursing and community care. A syringe driver allows medication – usually analgesics or antiemetics – to be infused subcutaneously over a long period of time, providing pain relief and comfort management even when medical professionals are not present. It is a sophisticated piece of technology; it recognised the type of syringe Liz placed in it, and adjusted accordingly, so that Donna would receive pain relief evenly and consistently until Liz could come and replace it. Before syringe drivers, Liz tells me, district nurses would have to run around the community, administering injections of pain relief at intervals as regular as they could manage, which of course required many night visits and many patients in discomfort – the invention of syringe drivers has drastically improved life for both nurses and patients in community healthcare.

After leaving Donna, Liz took me to see Roy* and his son Sam*. Sam was standing outside, and recognised Liz’s bright green car as it pulled up. He seemed distressed and tired, to be expected with his caring responsibilities and concern for his father, but nevertheless happy to see Liz arrive. Roy had end-stage lung cancer and severe chronic obstructive pulmonary disease, and was very clearly at the end of his life, cachectic and frail. He was sitting up when we visited him; lying down was too uncomfortable. It was difficult for him to speak, due to his heavily obstructed breathing, but he was perfectly cognisant and aware of his condition.

Sam told us that nights were difficult, as Roy often suddenly woke up breathless, which understandably caused panic, worsening the problem. He asked about the possibility of having oxygen tanks, but Liz explained that, in his case, this wouldn’t alleviate his discomfort any more than the medication which Liz had already prescribed for breathlessness and panic attacks. Roy’s skin was dry and he was spending a lot of time sitting down, putting him at risk of pressure sores, so Liz prescribed some cream, and arranged for an air cushion to be sent to their house. As well as treating Roy, Liz was concerned for Sam’s welfare, and offered extra help.

Sam was reluctant, clearly determined to look after his father on his own, but finally admitted that a night nurse would help him get some sleep, and be able to better look after his father in the day. When we were back in the office, Liz contacted Marie Curie to arrange for night care three times a week, to provide respite for Sam and extra care for Roy. This was perhaps the most emotionally challenging visit of the day, but seeing that Liz was able to arrange some more support for both of them was comforting.

Poor levels of education in the community often lead to confusion about diagnosis, prognosis, and treatment, to the point that patients and family members are unable to understand – or unwilling to understand – the true nature of their disease. This was clear when we went to visit Nick* and Denise*. Liz was treating a pressure sore and blister on Denise’s leg, wound care being a significant part of district nursing. Denise was also a stage 4 cancer patient. Denise had inoperable brain tumours which had severely impacted her mobility, but after Liz had prescribed steroids, following a symptom control review, the inflammation in her brain had reduced, returning a lot of lost mobility.

Nick seemed to be under the impression that the steroids were actively fighting the tumours, and that with enough steroid treatment, the tumours could shrink or even be eradicated. Nick was not an unintelligent man – this was clear in talking to him – but had clearly suffered from a lack of educational opportunities in life. It thus became Liz’s duty to inform him that, despite the outward improvement seen after starting the steroid treatment, the tumours were still incurable.

In just a day shadowing a district nurse, I began to see some of the challenges faced by the profession every day. District nurses work alone, often visiting patients with mental illnesses and anger management problems, sometimes in areas known for substance misuse and violence. A few of the houses we visited were unclean, to the point that it impacted Liz’s ability to provide healthcare quickly and easily – for example, not having somewhere to hygienically wash her hands.

The greatest difficulty that I saw on my day with Liz, however, had to be the emotional weight placed upon district nurses; district nurses and other healthcare professionals in the community see patients and their families at some of the darkest moments of their life, including their deaths, in their own homes. Nevertheless, the knowledge that such important care is being provided is comforting, and has clearly had an impact on Liz, who loves her job with infectious passion and enthusiasm.

I am at the very beginning of a career in medicine and healthcare, and I am so thankful to Liz and the QNI for instilling in me a great appreciation and admiration for the work of community nurses, and a recognition of the vital role played by community healthcare. It is not just nurses who serve the community in this way. A variety of healthcare professionals provide an invaluable service in communities across the UK, including but not limited to; GPs, midwives, occupational therapists, physiotherapists, health visitors, podiatrists, and health care assistants.

This integrated health care team allows patients with serious and chronic conditions to live as normal a life as possible, to stay at home in familiar surroundings with comfort and their loved ones, even when their health is failing. They relieve strain on hospitals by avoiding admission, managing conditions and injuries before they require hospitalisation. Rather than being divorced from acute or secondary care, primary care is a part without which the whole could not function, and is a sector of healthcare for which I have the greatest respect. I have no doubt that this appreciation will stay with me for the rest of my career.

*Names have been changed.