My first job as a State Registered Nurse in mid-1980s Britain was night shift on an Acute Geriatric ward in Portsmouth. The shifts were long—eleven and a half hours—and it was hard, physical work. All sorts of strange things happen at night. At times it felt as though the ward was bewitched—sometime around midnight. Hospital patients who were perfectly sane during daylight hours became confused, frenzied and belligerent after darkness fell. Nakedness, for some reason and for some patients, became an urgent necessity as did climbing over bed rails or side tables. Zimmer frames (walking frames) and walking aids so benign on dayshift, transformed into fencing weapons at night as patients who had bottled up a lifetime of frustration finally let go. Keeping sparing patients apart can occupy nurses for hours at night. Hiding potential weapons does not always help as water jugs and cups can become flying missiles at night. Patients in Britain, unlike the United States, cannot be physically restrained in any way and so “sitting” with an agitated patient is the only action to prevent falls or the accidental maiming of another patient.
As a student, I spent three months on night duty on a medical ward. I learned several things. First, the ward lights are only ever partially dimmed at night and so no-one sleeps. Second, the sweetest daytime patient can become demon-possessed at night. Third, even comatose patients regain consciousness at night and like to shout very loudly and those who go to physical therapy during the day like to practice walking and climbing at night. Fourth, medications given to promote sleep don’t work and more often have the opposite effect. Lastly, most deaths occur when the nursing team is exhausted.
I began my new job in April 1986. The ward had thirty-six beds and, more often than not, all were full. I was in charge at night with a State Enrolled Nurse (SEN) and usually two, or if we were really lucky, three Nursing Assistants (NAs). We were all entitled to an hour break during the night but sleeping during the break was prohibited and was cause for “instant dismissal” if discovered by the supervisor. Watching other people sleep made the need for a good kip all the more compelling and the knowledge that I couldn’t nap, even on my break, was the best antidote to insomnia ever. But I also knew that I was responsible for anything that happened on my break and that I couldn’t actually leave the ward unless the night supervisor relieved me which only happened if the rest of the hospital wasn’t busy.
Every night shift (and day shift!) began the same way with the ubiquitous tea round, followed by the nightly drug round that occupied myself and the other licensed nurse for at least an hour while the nursing assistants fluffed pillows, handed out bed-pans, escorted patients to the bathroom and generally tidied up the ward. Inevitably, if there was an empty bed it filled during the night as Casualty (ER) sent any patient over 65 with medical or surgical emergencies to my ward for observation or surgical preparation.
One evening around midnight, I answered the call from Casualty to say that they were sending us an elderly blind woman who had fallen down the stairs at home. No broken bones but she lived alone and needed observation and some social services before discharge. The patient arrived and I immediately began to orient her to the ward. “You are at the hospital in Portsmouth. You fell at home and so we are keeping you here tonight. My name is nurse Trudgen, I’m going to look after you” I began, “If you need anything, use this call bell and I will help you.” “Who are you?” the patient asked? “I’m the night nurse and you are in the hospital,” I replied. “Who did you say you were?” the patient asked again. Ah, thought I, she is also a little hard of hearing. I then proceeded to tell her more loudly that I was the night nurse and that she had fallen and was in the hospital. By this time we had an audience. The three other patients in the room were awake and apparently mesmerized by the conversation. My new patient was clearly getting upset and so I tried really hard to orient her to what was happening to calm her fears. Finally, the patient pulled herself up in bed and asked me in a very loud and indignant voice, “Nurse Turdgen, do you always break into people’s houses in the middle of the night?” Speechless, I tried to ignore the muffled chuckling of the other patients. I asked loudly if she would like a cup of tea. She said yes. I left the room only to return to the same conversation over and over again throughout the night. Apparently Casualty had “forgotten” to let me know my patient had recently been diagnosed with Alzheimer’s disease.
The next evening, another admission arrived, this time from the local city Psychiatric Hospital via Casualty. I was more prepared for a confused patient who might need some extra attention. My patient, a small and slightly emaciated woman in a fetal position, didn’t seem confused just frightened by her new surroundings. She refused a cup of tea and the bedpan and closed her eyes. That evening we were rushed off our feet. Call bells rang constantly and my team raced around trying to answer them all.
It was hectic. I called for help from the night supervisor as I had no other licensed nurse to help with the drug round (two licensed nurses were required to administer any drug in Britain). The night supervisor came, took one look and called another nurse to help her with the drugs while I answered the incessant calls. One patient in particular kept calling. She was in a four-bedded room with three other patients who were annoyed by her constant calls. I knew the patient from the two previous nights. The calling was unusual and after the fifth call, I decided to stay with her. I remembered being told in training that sometimes a patient can become agitated before a cardiac event or even respiratory arrest. I brought the crash cart into the room and called the nursing supervisor to get the EKG cart (it was shared between two wards). I then asked the supervisor to call the doctor. By this time I had a feeling we might need to resuscitate my patient and I wanted everyone ready. I pulled the curtains for privacy.
The doctor arrived quickly and placed the patient on the EKG machine and attempted to start an IV (doctors, not nurses, start IVs in Britain). The EKG machine registered a straight line. The doctor assumed the machine was faulty and asked the supervisor to get another. As she ran to get another machine, I looked at my patient and then tried to catch the doctor’s eye. She was intent upon starting the IV. The new machine arrived and the supervisor made the necessary connections and looked flabbergasted when the straight line night appeared yet again. The doctor, very frustrated by now, started checking the wires of the EKG as did the supervisor. Finally, trying to keep the other patients in the room from knowing what was happening, I hissed, “Look at the patient!” Even without a medical degree I knew she was dead. The doctor turned and her face suddenly registered the truth. The EKG machines were in perfect working order. Our patient had experienced a massive cardio-vascular accident that had killed her instantly. All our attempts to resuscitate the patient failed.
I knew from the notes that the patient was married and that her husband was wheelchair-bound. I didn’t know what to do. Should I call now and leave him grieving and unable to come in to the hospital all night? Or should I call early in the morning when his neighbors could drive him to the hospital? I decided on the second course of action especially as the ward was so busy.
Meanwhile, one of the nursing assistants came to find me. Apparently one of the patients had climbed out of bed and onto the nightstand and, wielding his orthopedic walking stick, had threatened to hit the man in the next bed. By the time we arrived back in the room, the patient had been assisted back into bed by another nurse but not before he had urinated all over his pajamas and the orthopedic lounge chair in front of his nightstand. The doctor who had followed me assessed the situation and ordered a sedative for the attacker and the potential victim. I filled in the incident report.
Just then, the semi-comatose uremic patient in the private side room began shouting for his mother. He was well into his eighties but I sympathized with his need for comfort and hurried in to see him before he pulled out his urinary catheter and IV. I was too late. The IV site was bleeding profusely and his penis appeared red and swollen and the catheter tip was bloodied. The patient was really agitated but calmed a little as I spoke softly and held his arm with one hand and reached for the call bell with the other. The doctor came running and re-started the IV and prescribed a sedative. Once the patient was calm, we changed the linen and I decided to call his daughter to come and sit with him as we were clearly understaffed. The patient’s daughter, a former nurse herself, came willingly and quickly.
Out of the corner of my eye I saw one of our patients walking towards the door with a suitcase in her hand. In a panic, I ran to the door and asked the patient where she was going and could I help? Without saying a word, the patient turned around and walked, suitcase in hand, to her bed. She then unpacked the suitcase and got back into bed. A few minutes later, I saw the same patient with her suitcase, making for the door again. Again, I ran to stop her escaping and she returned to her bed, unpacked her suitcase and got back into bed. I asked one of the nursing assistants to keep an eye on the patient and went to read her notes. The patient had fallen at home and was unsteady on her feet. The doctor had ordered intensive physical therapy that week. Clearly she was practicing and continued to do so all night, despite the sleeping pills.
I needed a cup of tea badly. It was 1am. Just then, one of the nursing assistants, apparently reading my mind, handed me a cup of tea and told me to sit down and drink it. I did as she told me and then she broke the news. The newly admitted patient from the Psychiatric hospital was dead. The SEN had taken her vital signs at ten; the supervisor had given her meds; the nursing assistant had made sure the patient was warm enough and comfortable and could reach the call bell. In all the bedlam of the past few hours, everyone thought the patient had fallen asleep. I ran to the office to check the patient chart. She was seventy-six, had no next of kin listed and had been institutionalized at sixteen. This patient, like so many others, had probably had an illegitimate child or had been caught with a boyfriend and institutionalized for life by her shamed family. I felt sad. No, I felt sick that this woman had died alone. I called the doctor. Horrified I came to understand that because this patient had died in the hospital before the passage of 24 hours, a postmortem was required. As I performed the “laying out” rituals I had been taught to show respect for the dead with the nursing assistant, I cried tears of shame that I had failed to show more respect and care for this patient during her life.
We finished preparing the patient, called the porters to take her body to the hospital morgue and sat down to another cup of tea. The ward had finally settled down for the night. It was 5.30am. We had thirty minutes before we had to start the morning routine—tea, drugs and blood pressures. We were all exhausted.
After the drug round was over, I went to the office and shut the door. I had to call the husband of my first dead patient. I rang and he immediately picked up the phone. For some unknown reason, nurses were not allowed to tell the next of kin that their relative was dead. I have absolutely no idea why. As I started to say who I was and that I was the night nurse at the hospital, the gentleman interrupted me. “Is she gone?” he asked. “Yes,” replied and added truthfully that I was with her when she passed away. He thanked me profusely for that act of kindness and then told me he had been unable to sleep all night because he “had a feeling something was wrong.” I felt sick. Had I made the wrong decision not to call him until the morning?