When I started my internship at the QNI I knew that I would immediately take any opportunity to shadow a Queen’s Nurse. In fact, during my time at the QNI, I have been lucky enough to shadow two different nurses: a District Nurse and a Homeless Health Project Nurse, giving me two completely contrasting experiences.

A District Nurse

My first experience of shadowing a nurse was with Debbie White, who had become a QN in June 2019. I arrived to meet her at Harold Hill Medical Centre at 8:30am and was introduced to the team of District Nurses based there. The nurses at Harold Hill are split into three teams covering different areas of Havering, with Debbie being the team leader for the Collier Row area. The role of the district nurses is to go into the community and visit patients who are deemed to be housebound with no way of accessing medical care at a GP surgery. Across the three teams, the nurses have about 200 patients at any one time, with each team usually seeing 30 patients a day, regardless of the number of nurses available.

Agnieszka

The first patient that we saw was a lady called Agnieszka, who required a B12 injection. Agnieszka needed a series of six injections which were to be administered across two weeks. This visit was for the fifth injection and was the first time Debbie met Agnieszka, as she had not delivered the previous four jabs. When we arrived it was apparent that Agnieszka was expecting the previous nurse and was unsure about the unfamiliar faces. Debbie was very calm and kind, introducing us both to Agnieszka, and explained that because of the nature of district nursing it is not always the same nurse assigned to administer repeated injections to patients.

Debbie knew that Agnieszka had been a university professor, so asked her questions about her previous work in order to allow her to talk about herself and feel comfortable. Debbie did everything to put Agnieszka at ease and when she was happy Debbie gave her the injection.  This illustrated how a quick visit to give an injection actually took much longer than planned, because of the time and care needed to make the patient comfortable and have the best experience.

Nancy

District nurses also carry out assessments for patients who require end of life and palliative care. This was the case for the next two patients we saw that morning. First was Nancy. Nancy was an elderly lady who had been diagnosed with carcinoma. When we went into the dining room we found Nancy with her son eating some breakfast. Debbie sat down and asked Nancy various questions to see if there was anything that she could do to help, particularly with managing any pain. Debbie offered pain patches, anti-sickness tablets and sachets of nutrient powders to make drinks in case Nancy didn’t feel like eating much. As well as talking to Nancy, Debbie then went on to ask her son some questions to make sure that he was being supported too.

Ken

We had a similar encounter with the next patient, Ken, who was an older gentleman receiving chemotherapy for symptomatic relief of stage 4 lung cancer. Ken had previously been the sole carer for his wife with dementia, but because he was now ill himself his wife had other carers. For this visit we stayed for nearly an hour talking to Ken and his son about any concerns that either of them had. Debbie asked him about the side effects of his chemotherapy and offered him anti-sickness tablets. She also gave him guidance on getting carers to come in for him, as well as for his wife, in order to help him change the bags on his catheter.  This palliative aspect of district nursing was completely new to me and it really emphasised the value of allowing a patient to have a comfortable death at home with their loved ones. It also demonstrated how district nurses support and comfort those who are important to the patient.

Matthew

The final visit of the day was to a 95-year-old man called Matthew who needed his ears syringing. Matthew was very deaf and it took Debbie a few attempts to explain what was going to happen. Matthew’s wife was very chatty and Debbie would also communicate with her to make sure that they both knew what she would be doing. After syringing Matthew’s ears, Debbie went above and beyond her role when she noticed the red, dry skin on his wife’s hands. Debbie told her she suspected she had contact dermatitis and went online to show her some creams that she could think about using. She also took the time to make sure that his wife was not struggling through being Matthew’s only carer and gave her information on how to arrange carers if she wanted them.

A homeless health nurse

The second of my shadowing experiences was with Kirit, a homeless health nurse. For this particular day Kirit was based at a hostel in Southwark working with the Street Population Outreach Team (SPOT) who are part of St Mungo’s charity. At the hostel they have funding for Kirit to spend 2.5 days per week with them for client-facing outreach homeless nursing. Outreach nursing involves the nurse and the SPOT workers going out into the borough of Southwark to try and find either specific homeless people with known injuries that need attention or anyone who needs medical help on the day.

Hannah and Paula

In the morning, Darren (a member of the SPOT team) drove us to a place where two men were known to be sleeping. Darren wanted them to see Kirit for general health assessments. When we arrived we found the bedding set up, but nobody there. Darren tried a couple of locations that he thought they might have gone, but we still didn’t see them. We then got back in the car to drive around to try to spot two ladies. Hannah was known to have been discharged from hospital a few days ago after being admitted with head injuries and Paula had been spotted with a serious abscess on her neck. We drove around the ‘usual’ places for them to be in the morning, but we had no luck seeing either of them.

This was the first huge contrast that I noticed between district nursing and homeless outreach nursing – the planning. With Debbie we had a specific list of patients, addresses (where we knew we would find), and treatment. For the homeless outreach nursing you often have to just try and look in usual spots where you think the homeless person will be or where you know they are sleeping. Even with all of the planning to decide which patients to try and find, you usually don’t have a specific place to meet them and if you cannot find them during the outreach session, you can’t evaluate their health needs.

Ricardo

Finally, we did manage to find a patient that we were looking for. Ricardo was living in a subway near London Bridge. Darren knew that Ricardo had been ill recently, in and out of hospital and was on various medications from a GP surgery, which is why he brought Kirit to check up on any issues he might have. Ricardo refused to allow Kirit to dress any of the sores on his legs or to give him a general health check-up. This is the second difference I noticed – in homeless outreach nursing even if you find a patient you cannot force them to have a health assessment. There are several reasons why Ricardo might have turned down Kirit’s help: he might feel he doesn’t need it because he is registered with a GP, he might feel healthcare is not a priority if his most basic needs of eating and sleeping somewhere safe are not being met, or he might have had a bad experience with healthcare professionals in the past.

Thomas and Felix

After the morning outreach we went back to the hostel where I met Graham (another member of the SPOT team). Graham had been out looking to see if there was anyone that needed medical attention. He had identified a man with a pink eye, which he suspected was infected. Graham had spoken to the man, named Thomas, and asked him if he wanted a nurse to come look at his eye. Thomas had said yes but told Graham he was going to try and buy some food, so would be back in 20 minutes. Graham relayed the information to Kirit and told us he was sleeping near London Bridge Station. After 20 minutes, Kirit and I reached the location but Thomas wasn’t there. Kirit decided that we should walk around the area to see if we could spot him or anyone else that might need help in the meantime.

During this time we found Felix, who is known to Kirit. Felix was sleeping in thick black clothes in direct sunlight and was sweating a lot. Worried about him becoming dehydrated, Kirit tried to wake Felix up to help him move into the shade. Felix told Kirit he didn’t want to move and have a chat. Again, it was a situation where we could not force someone to do something they didn’t want to do. Instead, Kirit left him with some water and we went back to try and find Thomas. He still wasn’t back.

This highlighted the third main difference: if you cannot find someone during homeless outreach you cannot contact them. If a patient does not answer the door for a district nurse the nurse will try to ring the patient and the patient’s relatives. This is to determine why they did not answer the door to rule out that they are still in the house alone. With homeless outreach, if you cannot find someone you might just have to wait until you serendipitously run into them, or until you do outreach the following week.

Michael

The final trip for the day had been arranged for 1:30 pm at a Job Centre to see a patient called Michael. Michael was homeless, but was known to never engage in healthcare or any appointments unless it was at the job centre. One of the staff at the job centre had contacted the SPOT team saying that they were worried about Michael and wanted him to see a nurse. As a result, Kirit and I had to go to the job centre to stand any chance of being able to give him a check-up. When we got there Michael was very co-operative, despite his past record with refusing health care. He was happy for Kirit to examine and clean his feet and then to take his blood in order to run tests for infections.

Conclusion: the kindness of nurses

In just two days I got to see some of the main challenges facing two different types of community nurses. With Debbie, I saw how she has to work alone, visiting patients that can be difficult in homes that can be unclean (to the point where it is difficult to administer health care quickly). With Kirit, I saw how it is incredibly difficult to plan the delivery of healthcare to homeless patients, when often you just have to try and run into them in places you suspect they might be. It can also be incredibly hectic because when you see someone in need, you have to just take that chance to assess them and give them help if they want it.

With both nurses, the thing that resonated with me the most was the kindness. Both Debbie and Kirit loved their jobs and loved to help the patients they saw. Everything they did was conducted in a calm, kind manner. Their work carries a large emotional weight, with district nurses seeing patients and families during terminal illnesses coming to terms with death, and homeless outreach nurses seeing patients at one of the most vulnerable and desperate times of their lives. I truly admired both Debbie and Kirit and the work they did whilst I shadowed them and I will always remember my experiences shadowing them both.

Alice Knapton, QNI Intern

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