BELLS, BEDPANS & BURNOUT

The reality of working bedside in the NHS

Blog

  • Alternative dietary requirement

    Slight to begin with, Madhur has lost weight since her admission to us 3 weeks ago. At 160cm (5’3”), she now weighs just 37kg (5st.11lb).

    After noting the measurement displayed on the screen, I indicate that she should step off the scales and I walk with her back to her bedside. I tell her she has lost weight. “Yes”, she replies, smiling up at me and patting my arm with her bony hand. I’ve looked after Madhur enough now to know that, as an Urdu speaker with very little English, “Yes” is her go-to response when she doesn’t know what has been said. Back at her bedside, I look at a piece of paper with words like “pain”, “nausea” and “water”, helpfully written out in both Urdu and English by Madhur’s son. There is nothing there I can use, so I pull out my phone and talk to Google, showing her the translation on the screen.

    The use of automated online translation services is not recommended practice in the NHS. Rather, we are encouraged to use Language Line, a third-party service that connects your call to a trained interpreter for which the ward pays by the minute. Whilst this service is considered a must during medical consultations, it is rarely employed for the ongoing and haphazard communication that occurs during everyday bedside care. This is navigated with a mix of precise enunciation, charades, Google Translate and the engagement of patients’ friends and relatives.

    I draw on this last resource later in the afternoon when I see Madhur’s son. “Other than toast and jam at breakfast, she barely touches her meals. Does she not have much of an appetite?”. He explains it’s not her appetite, but the food that is the problem: “I mentioned it to your colleagues, but they just keep ordering the same thing”. Turns out that despite enjoying a wide range of food, she’s been being given the same two meals for lunch and dinner for the last 3 weeks – a vegetable or chicken curry, one for lunch, one for dinner, sometimes swapped around but always the same.

    This might have been surprising considering the Trust boasted “a wide range of menu choices including Afro-Caribbean, halal, kosher, vegetarian, vegan and gluten-free options” which could all be found on an “additional dietary requirement” menu. This was handed out upon request but for the majority, the standard menu was given, which included a range of hot meals, salads, and sandwiches.

    “My mum likes pasta, sandwiches. She’s not even Muslim!”  

    I winced thinking about the assumptive behaviours that had led to Madhur only ever being offered from the alternative menu, despite not having any additional dietary requirements. It seemed more than likely that this was rooted in the same line of racial stereotyping that was leading to someone repeatedly and inappropriately ordering halal curries for her.

    The catering staff that took Madhur’s lunch and dinner orders worked for an external supplier. They only came around in the morning and were not present to witness plates of food being delivered and taken away uneaten. They used an ordering system that was inaccessible to ward staff and could not be amended. Only the food that was ordered was delivered so ward staff were limited in what, if any, alternatives they could offer later. The only way they could intervene would be to collar the catering staff while they did their morning orders, for which bedside staff weren’t always available or quick enough to catch them.

    Perhaps it was because of these gaps in communication or because they were short on time; perhaps it was because they worked in isolation or maybe they were not adequately trained; perhaps they weren’t thinking or maybe they just didn’t care. But whatever the reason, when language barriers prohibited Madhur from choosing from the menu, instead of taking the time to muddle through translation or speaking to a member of ward staff, the catering staff were simply selecting what they presumed to be the most suitable meal for her – a curry.

    To help manage this, I sit down with Madhur’s son to make a list of items titled “I like to eat:”. We stick this list on the patient information board above her bed with “FAO catering staff” written boldly at the top.

    Pleased with this initiative, I reassure her son that from now on she’ll receive a variety of meals which will hopefully help her appetite.

    The next morning I’m stood at the bay entrance when a member of catering staff arrives to take Madhur’s order. “Veg curry?” he says. “Yes” she replies.  

  • Full disclosure

    On our annual off-ward training day this year, I listened with small astonishment to the utter nonsense some of my colleagues were spouting.

    The training consisted of a number of sessions on different fundaments of care, including patient nutrition, hydration, mobilisation and deterioration. Each session was led by a member of the clinical team with a professional interest in the subject – dieticians, researchers, critical care nurses etc – and involved at least some element of interactive activity from the twenty or so nursing staff in attendance. Quite often this included questions regarding our role and actions taken: “how do you conduct a risk assessment”, “how should you respond” etc. In answering, however, there appeared to be very little discernment between what you should do (or work-as-prescribed) and what you would actually do (or work-as-done). And much of what they described did not at all match the reality of what I had witnessed and experienced on the ward.

    The gap that exists between work-as-prescribed and work-as-done is well established in existing literature and has been extensively explored in a range of ward-settings. In healthcare, much discussion focuses on how the gap might be narrowed to in such adaptive environments where no two interactions are the same. What is noted in a lot of these studies, however, is that the reality of this gap is often obscured by staff reporting. For many reasons, staff descriptions of what they do (or work-as-disclosed) often more closely aligns with work-as-prescribed then work-as-done. While possibly due, in part, to the difficulty of distilling complex, haphazard and messy scenarios into clear descriptions of process, Suzette Woodward writes that this phenomenon is likely due to existing cultures in healthcare discouraging people from speaking out.

    In a strict hierarchical environment, in which your professional registration is tied to an ethical and legal responsibility to uphold safe and quality care, admitting not following best practice comes with significant personal risks. And while the circumstances that might have led to any shortfall in care might not be the individual’s responsibility – such as chronic understaffing, excessive workloads, patient acuity, inadequate resources and support from management – staff have learnt that speaking out about these things is very unlikely to lead to anything being done about them. Unless you feel as though your response is valued, that it is being listened to and leant from, then answering honestly as to reality of the day-to-day constraints on practice might feel like too much of a personal risk to take, especially when you know your admission is unlikely to affect change.

    When looked at like this, failure to disclose work-as-done might be understood to be driven less from a “culture of fear” and more from a “culture of indifference”, in which the reality of working conditions is assumed known but not cared about.

    This was something that was felt particularly acutely on non-critical care wards during the pandemic. Staff were redeployed from these areas to service ICU and HDU in order to maintain the 1:1 and 1:2 staff to patient ratios in these areas closely as possible. General wards, however, remained open, full and significantly understaffed. This was true of the second wave especially, when winter pressures and the fall out of the first lockdown meant high admission rates. During this time, the ward I worked on was staffed at 8:1 and 9:1 as standard (I know of other specialities that were at as much as 12:1) and our ability to do our jobs was significantly compromised. We saw the impact this had in the timeliness and quality of care we delivered, and witnessed the effect this had on patient outcomes, complications and deaths.

    The divisional managers would regularly come by and ask us how we were doing. We would answer that we were understaffed, overstretched, and exhausted; that we couldn’t keep our patients safe, were unable to complete basic care tasks, and that patients were in pain and dirty and dying alone. And they listened and nodded and thanked us and continued to take staff away.

    We understood why it was happening, we also understood that management were probably doing their upmost to protect staff and patients, and that there was likely very little that could be done. But it felt as though no one cared.

    Even now, out of the dozens of inquiries and reviews into staffing during the pandemic, very little is known or written about nursing numbers and outcomes on general wards. And the NHS is still yet to mandate a minimum nurse-to-patient ratio across England.

    Back to our training day, and it appeared that staff chose from two types of responses when asked about their work. While a few emphasised their inability to do the task as prescribed due circumstances and constraints, the majority described working as prescribed – often even repeating the evidence basis and rational for practice. It wasn’t that they were intentionally misleading anyone. Rather, it likely seemed easier, safer, and perhaps even futile to acknowledge the full extent of the challenges they faced in doing their job the way they knew they should. Considering the context (a learning environment where the staff’s knowledge basis was being assessed) this pattern of responses is hardly surprising. But it is revealing.  

    The training day was a clear reminder of the gap between how care is supposed to be delivered and how it actually happens on the ward. This disconnect isn’t just theory—it’s something staff deal with every day, shaped by heavy workloads, staffing shortages, and a culture that makes it hard to speak openly. This reluctance to speak is part of a broader issue in healthcare, where the gap between policy and practice is not just overlooked but not likely not adequately understood, making it even harder to address. Without real efforts to listen and act on what frontline workers experience—especially during crises—healthcare risks staying stuck in a cycle where problems are ignored, staff feel unheard, and patient care suffers as a result.

  • Emily

    [05/09/2019]

    Emily is quietly dying. My experience tells me that it is not the kind of dying you recover from. Yellow and puffy, she is exhausted from just staying alive. She lies in her bed at the entrance to the last bay (where the most stable/independent patients are usually put) and I see her every time I pass by: Lying flat with her dark hair spread in waves across her shoulders, its red colouring contrasting with her sallow skin. At 35 she is just a couple of years older than me and the calmness with which she faces both the struggle of her present circumstances and the loss of her future speaks volumes about her overall character. She is unquestionably one of the most kind and considerate people I have ever had the privilege to look after. Always patient, always polite, staff talk about her with a fond sadness that reflects the fact we all know she won’t be with us much longer, even if it is not openly discussed.

    [08/09/2019]

    Emily is catheterised now. They had wondered if she was retaining urine, but she wasn’t producing any. Her renal system has started shutting down. There is lots of discussion about how much of her deterioration was due to disease progression, and how much was due to her treatment. After administrating what was supposed to be the first bag in a final round of chemo, Emily rapidly deteriorated. So much so that they decided to not continue. It was never going to be curative, but if the cancer had responded, either slowed or stopped growing, it could have given her more time. The chemo nurse tells me that she regrets administering that final dose, “but who wants to tell a 35-year-old that she’s no longer appropriate for treatment”.

    [10/09/2019]

    Emily has been moved, brought to a bay in the middle of the ward so she is closer to the nurses’ station. She lies awkwardly, never comfortable. Her limbs heavy with fluid, skin stretched taught. At this point care staff are assisting with all her personal care needs as she is just too weak to do much of anything for herself anymore. Helping her reposition in bed, I am shocked to see the blackened skin of her sacrum when she rolls over. Necrotic damage to deeper layers of skin a clear indicator that her body is breaking down, unable to heal. The cancer specialist nurse has been discussing the reality of Emily’s prognosis with her. She seems receptive to this – very aware that her body is failing her and too tired to fight it. It is documented that she confirmed that she understood that nothing more that could be done to treat her cancer, that priorities now are keeping her comfortable and meeting her wishes of being able to spend time at home before going to her preferred place of death which is the hospice.

    [11/09/2019]

    Emily seemed brighter this morning – the blood transfusion overnight must’ve helped. After being practically bed bound, she was up and walking when we arrived on shift. Making the most of this, I offered her a shower. I made sure to take my time, knowing that there is no guarantee she will be able to get back in there again. I massage my fingers into her scalp, building up a lather of shampoo as hot water rains down. I comb coconut conditioner through her hair and, once she’s dry, cover her in body butter. She talks to me throughout it, telling me about her family and the pets she had growing up. Having exerted herself from this, she stays in bed for most of the rest of the day, getting increasingly uncomfortable as the evening drew on.

    This is hard to deal with. Whilst acute pain is horrible, and its management complicated, employing medication for its relief is well established and staff are usually in agreement about appropriate usage. The chemical management of discomfort, restlessness, and agitation on the other hand, is less readily employed as its sedating effects make it seem an extreme measure. Emily has made it clear that she would rather be alert and uncomfortable than so doped up that she cannot be awake and experiencing the world for the remaining time she has in it. We are doing all we can to keep her comfortable – endlessly adjusting pillows, limbs, bedding, heat pads, the electric bed, and taking blankets off and on. But nothing seems to bring any relief for more than a very short amount of time.

    [13/09/2019]

    Emily asked for me today. She asked yesterday too, but it was my day off and she said she would wait until I am back to have another shower. The team accommodates, working out patient allocation to ensure I have adequate time with her. Its only two days since we last did this, but this time she struggles every step of the way.  I must help her with everything – sitting up, moving to the edge of the bed, putting on her slippers, standing up – and she is exhausted by the time we get to the bathroom. I carry on but am inwardly worried we won’t be able to make it back without using a hoist. She doesn’t talk much this time. Just sits slumped in a plastic chair, her eyes closed, as hot water runs over her hair and puffy, swollen body. I gently pass the soapy flannel across her skin which, along with the whites of her eyes, is now an almost illuminous yellow and stretched so tight that I’m scared it will split if I’m too rough. Her long, thick, dark red hair, still so soft, seems to be the only part of her left unchanged from this disease.

    The complexity of her care needs means that her original wish of spending time at home is no longer feasible and we are now organising her discharge to hospice. I am sorry that going home isn’t possible but glad that she is leaving the hospital for somewhere more suited to what she needs, where she can have her own room and her parents can stay. “They can even bring the dog”, she tells me smiling.

    [14/09/2019]

    Emily left us today. A hospice bed became available overnight and she was taken there by ambulance this afternoon. Wrapped in blankets and strapped into a trolley, I walk with her as she is wheeled across the hospital forecourt. For the last 5 weeks that she has been with us, she has not been outside, has not been able to open a window, has not felt fresh air on her face. Its grey and drizzly, but she turns her face up into the rain, shrugging her arms free and holding them up to the sky, smiling and blinking in the light.

  • Half an hour of hand hygiene.

    13:30

    Enter patient bay, wash hands with soap and water, measure Bed 1’s vital signs.

    Use alcohol rub, don gloves, use chemical wipes to clean equipment.

    Doff gloves, wash hands with soap and water, use computer to update patient’s notes.

    Use alcohol rub, measure Bed 2’s vital signs and assist back into bed.

    Use alcohol rub, don gloves, use chemical wipes to clean equipment.

    Doff gloves, wash hands with soap and water, use computer to update patient’s notes.

    Use alcohol rub, measure Bed 3’s vital signs.

    Use alcohol rub, don gloves, use chemical wipes to clean equipment.

    Doff gloves, wash hands with soap and water, use computer to update patient’s notes.

    Use alcohol rub, answer patients call bell. Put on patient’s socks and slippers, walk patient to bathroom and back.

    Use alcohol rub, don gloves, take collected urine to be measured.

    Doff gloves, wash hands with soap and water.

    Use alcohol rub, use computer to update patient’s notes.

    Use alcohol rub, measure Bed 4’s vital signs.  

    Use alcohol rub, don gloves, use chemical wipes to clean equipment.

    Doff gloves, use alcohol rub, don gloves, measure and empty patient’s catheter.

    Doff gloves, wash hands with soap and water, use computer to update patient’s notes.

    14:00

  • “colostomy pink and warm to touch”

    Included in the notes from the morning’s ward round, which stated that the patient was medically fit for discharge, this short statement demonstrated that none of the 4 doctors in attendance had reviewed any of the nursing notes, or actually looked at the patients colostomy, in at least 6 days. Because if they had, they would have seen that the protruding section of large bowel that made up the colostomy site was not pink nor warm, but black, necrotic. It was dead. A small hard lump of strangulated flesh, set within the warm, softness of the patient’s belly.

    The patient, David, was 9 days post-colostomy, a kind of surgery in which the colon (large intestine) is shortened and the newly cut end diverted through an opening created in the abdominal wall, known as a stoma (Latin for “mouth”). Post-op, patients are expected to make a quick recovery – mobilising after just a few hours and building up to a solid diet within a few days. David had hit all the milestones necessary on the road to a successful discharge. He was up and out of bed within 12 hours, had a successful trail without (urinary) catheter within 24 hours, was off his patient-controlled morphine pump by day 2 and had his midline wound staples removed on day 7. In this time, he had built up from sips to clear fluids, to free fluids, to a low fibre diet, and his stoma had been active with a good output correlating with his intake. He had been trained by the specialist stoma nurse and was emptying and changing his colostomy bag with their supervision.

    When the doctors had spoken to him on their round that morning, he was able to tell the team that he wasn’t in pain, was eating and drinking well, that his output was good, and that he was able to care for his stoma independently. Happy with his answers, and after checking his midline wound, the team were pleased to be able to tell him they would be discharging him that day. They accepted his thanks, said their goodbyes, left the ward and David began packing his bags. Not too long later, dressed and raring to go, he asked his nurse if he needed to wait for anything or could just call a taxi and was taken aback by their response.

    David’s trust in his medical team contrasted with his experience of the unreliability of the nursing team. Throughout his time as an inpatient, he’d seen at least some members of his surgeon’s team everyday – even at the weekend. Whereas his nursing team changed twice a day, every day, with new and rotating staff. When he had seen the same nurse more than once, they might have been working elsewhere on the ward or had days off in between shifts. He was constantly being asked the same questions and having to repeat important information. And was always either updating them on things they should know, or they were suddenly changing things without warning.

    This meant that when David was told by his nurse that, despite what his doctor said earlier, they weren’t actually going to be discharging him today, he knew that she must be mistaken. And when she tried to explain that the nursing team were disputing the doctors’ decision, he was furious. He had been told by his surgeon that he was medically fit for discharge and, as the authority on these matters, his surgeon should be listened to.

    He told the nurse this. Indignantly sharing his various observations about their incompetence and listing a number of occasions when, even though they knew what they should be doing, they hadn’t been organised enough to get it done: He had been scheduled to go for surgery at 8am, but had waited on the ward until mid-afternoon; there had been a huge delay taking down his morphine pump; and after being told that he could start eating solid food, they never ordered his lunch.

    Unrecognised by him, however, the nursing team had actually been working incredibly hard to keep him safe. When an emergency admission on the day of his surgery led to it being cancelled, they had fought for him to still be taken down later that day – arguing that existing comorbidities meant he was at high risk of complications from not being able to eat, drink and take his regular medications for any sustained amount of time. Similarly, after surgery, they needed to make sure alternative oral medication was available when they removed his morphine pump. An adverse reaction to analgesia had meant they had to consult with a specialist pain team and then wait for his doctors to prescribe based on their advice before it could be taken down. Finally, although they had known he should be moving onto solid food, without written documentation from the medical team regarding this decision, they could not just let him start eating. After chasing and failing to get it confirmed in time for lunch service, one of the nurses had had to run to the kitchen to collect a packed lunch for him later that afternoon.

    Even now, their decision to delay his discharge was in his best interests. Stoma necrosis is considered a medical emergency that usually requires urgent consultation with surgical services. While minor stoma discolorations can be monitored closely during the early postoperative period without requiring surgical intervention, severe necrosis necessitates timely stoma revision.

    The nursing team had first noticed discolouration in David’s colostomy site when changing his stoma bag 6 days ago. They had highlighted this via David’s electronic health record (EHR) and uploaded images for the medical team to review. That was on the Wednesday.

    On Thursday, they had told the surgical team told directly. Having already assessed the patient and without seeing the stoma, the doctors had documented a plan to discharge David after the weekend. They were just about to leave when David’s nurse caught up with them and passed on their concerns. The nurse documented this interaction, and that the surgeon confirmed that it should be closely monitored and to keep him updated.

    The next day, however, the surgical team came early, before bedside staff had had a chance to empty and change David’s stoma bag. Contained within an opaque brown bag that was full of faecal liquid, and working under time restraints, they did not wait for it to be uncovered. When the stoma nurses changed the bag later that day, the bedside nurses took and uploaded new images and messaged the team to say they were available. It was late afternoon before one of the junior doctors messaged back instructions to “continue to monitor”.

    Following this instruction, both times David’s stoma bag was changed over the weekend they had added new images to the EHR; documenting the spread of greying flesh slowly turned black. They continued to keep a record of their interactions with the surgical team, including two requests for reviews from the on-call staff (both Saturday and Sunday) but were advised by them to wait until the senior surgeons were back on Monday.

    By Monday the stoma was clearly dead. And yet, despite this, the surgeons continued with their planned discharge. How could this happen?

    Whilst stoma necrosis is a recognised complication of colostomy surgeries (with some associated risk from surgical technique, emergency operations, obesity and anatomical differences) identifying a root cause for individual cases is near impossible, and it is normally assumed to be a combination of factors. Similarly, the delays in diagnosing David’s stoma necrosis came from a combination of factors that hindered communication and decision making, making it impossible to pinpoint individual responsibility.

    Firstly, strict demarcations around roles and responsibilities meant that, whilst highly skilled at conducting colostomy surgery, it is highly unlikely that any of the surgeons or junior doctors have ever changed a patient’s colostomy bag. Almost all wound and stoma care is conducted by nurses postoperatively. And whilst a wound might be uncovered by the surgical team and then left to be redressed by the nursing staff, the extremely high likelihood of the stoma bag being full of faeces means that doctors are very unlikely to uncover or request for the site to be uncovered during a ward round. Instead, the site is only ever really uncovered when the bag needs changing. This done either by ward or specialist stoma nurses until the patient is adequately trained. This means that doctors were completely reliant on patient and nurse feedback as to what the site looked like.

    Opportunities for feedback was, however, very limited. On this surgical ward the bedside rounds happened quickly and early, before the consultants went into surgery for the day. I’m not sure whether it was a requirement or a formality for bedside nurses to be involved in rounding, but I do know that whilst the nurses were keen to be there, doctors would often conduct them regardless of their presence. When they arrived on the ward they would go straight to the patient’s bed space. If the nurse looking after the patient did not witness their arrival and drop what they are doing to join, they were not sort out or waited for. Instead, they were expected to consult the doctors notes in the EHR for any updates they might have missed. This meant that while the nurse managed to catch them before they left rounds on Thursday, no nurse was present for the surgeons’ conversations with David. Meaning that their observations regarding David’s colostomy remained absent from the ward round notes.

    Furthermore, whilst ward nursing staff will work a whole shift at the bedside, other teams are often spread across multiple wards, departments and even buildings. Meaning that majority of cross-team communication outside of ward visits happens over the phone or via the EHR. The excess of data contained in the EHR means it has been designed to streamline information, with many sections hidden or inaccessible, depending on your role. The lack of tech available on the wards also means that doctors on their rounds are often forced to use their own mobile phones during rounds, using an app that presents only a limited view of patient records. Because of this, and because they were so short on time, doctors routinely just opened and followed on from the last ward round notes; copying and pasting relevant information, checking and updating test results and actions, but bypassing any nursing or miscellaneous entries.

    For these reasons, perhaps, the pictures, notes and messages concerning David’s possible stoma necrosis were missed by the surgeons. Furthermore, where these gaps might have been normally filled in by the patient, because David – who was aware of the nurses concerns and assumed the doctors must be up-to-date with everything – was never asked by the surgeons about the colour of his stoma, he never thought to mention it. It is likely that, on Thursday, without the ability to routinely undertake stoma site checks, and without a nurse present to tell them otherwise, it is likely that the junior doctor taking notes for the team simply did not update a note that had been copy and pasted across from Tuesdays ward round stating “colostomy pink and warm to touch”. This error was then carried over to the following Monday.

    Back to Monday afternoon, David’s nurse listened patiently to his complaints and then apologised for all the delays and issues he had experienced with his care so far. This wasn’t done to pacify him. It was partially said as an honest admission that things could possibly have been done differently and better. But mostly it was said because there was nothing to be gained by pointing fingers at other teams or team members when the majority of delays were down to due process.

    Unfortunately for bedside nursing staff, their role meant they were often the face of every delay, mistake and miscommunication, even if not directly responsible. Whilst it may have been true that on some of the instances of delayed treatment David listed the nurses were “waiting for the doctors”, to respond this way would have done nothing to resolve any of the systemic issues that led to these delays: the imposed restrictions of the electronic records system, staff working patterns, and teams operating in silo, leading to gaps in communication and lengthy deferrals to senior decision makers.

    David’s nurse apologised again that he had to wait but explained that their concerns regarding his stoma needed to be resolved before he could go. Recognising that he had a good relationship with the specialist stoma nurses, feeling seen and supported by them during their almost daily interactions, they reassured him that they would be along to oversee things and made arrangements for one of the medical team to come back to assess the stoma site with the bag removed.

    By mid-afternoon David’s notes had been amended to document that his stoma was necrotic. Before the evening, he had undergone a pre-operative assessment and been consented for urgent surgery booked for the next day. David’s second surgery went well and he was successfully discharged 10 days later.

    He never did forgive the nurses for messing up the first one so badly.

  • Bowels Open – Type 7.

    “Ready, steady, stand”

    With the flat of my hand resting at the base of her spine, I gently push to encourage Corrine as she moves from sitting at the edge of her bed into a standing position. Holding on to her zimmer frame with arthritic hands, she begins the slow shuffle towards the ensuite bathroom of her private room. Corrine was moved to this room so that she could be isolated from other patients after testing positive for clostridium difficile or “c-diff”. Most commonly occurring is those taking broad-spectrum antibiotics, it is easily spread to others and can be life threatening, with profusive watery diarrhoea leading to dehydration, colon damage and even sepsis. Despite my best efforts to respond to her call bell, don the required PPE and assist her out of bed as fast as possible, I wasn’t quite quick enough. As we cross the room odorous brown-green liquid begins running down the inside of Corinnes legs, over her surgical stockings, and dripping across the floor. I look back at the bed she just got out of and see the trail leading from us to a small stain where she was just sitting.

    Neither of us mention it. When we get into the bathroom, I silently pull her nappy down before helping her lower herself onto the toilet. I say I’ll give her a few minutes and leave to strip the bed and wipe up the mess. Despite her frailty, Corrine is fiercely independent. Recovering from a broken hip after a fall, she has worked doggedly with the physios to complete her rehab to get back home as soon as possible. This infection has really set her back. Not just delaying her discharge, but sapping the strength she has built up and the energy she needs to recover. This is the third time I’ve taken her to the bathroom since the start of my shift and her legs are now trembling with the effort of it. Although she has been managing her hygiene needs pretty much independently, when I return to the bathroom it’s to suggest I help her with a wash. Exhausted she agrees, and shyly asks if I can help her shower – no matter how much she wipes herself she just doesn’t feel clean.

    Performing the required hand hygiene protocols on exit and entrance, and re-donning PPE, I return with pants, a nightdress, socks, towels and disposable flannels. I help her strip off and sit her in a plastic chair in the open shower area of the bathroom. The water runs hot and makes the air in the room feel cold. I have to stand holding the hose over her body to stop her from shivering as she lathers her hair. She leans her head back and I rinse out the suds. Proximity means the bottoms of my trousers, shoes and socks are quickly soaked. She manages to most of it herself, but I have to help her flannel her back and feet causing soapy water to run down my arms and fill the inside of my plastic gloves. Shakily she stands, holding on to a handrail, so that she can wash her bottom and between her legs. The effort of standing causes her bowels to open and the rising steam fills the room with the distinctive smell of clostridium difficile. The pooling water begins to discolour and I take a step back to avoid the spreading faecal matter from absorbing into my already soaked shoes.

    Its a small while before Corrine leaves the bathroom. Once dry, dressed and wrapped in a blanket, she sits waiting for me to make her bed. Looking small and grey, her eyes are closed before I finished pulling the blanket and sheets over her. By the time I leave, carrying bags of laundry and pulling the door closed behind me, it’s been almost an hour since I first answered Corrine’s call bell. And despite the time, energy and coordinated effort it took from both of us, anyone looking in would barely be able to notice anything had changed in that time, seeing only a tired and sick, but clean and comfortable looking woman lying in a freshly made bed in a silent room. Nappies and socks have been binned, faeces wiped, washed, and flushed away, and all soiled textiles anonymously bagged and shipped to an industrial launderers. In the end, the only visible trace of our activities will be found on her electronic health record, under her “Fluid Input and Output” chart, where I have selected a box marked “Bowels Open – Type 7”.