Care home nursing: the world's largest relay race?

published in The Hippocratic Post,
13 August 2019

link to The Hippocratic Post article

In a relay race members of a team take turns completing parts of a course, with relay being defined as the act and consequence of replacing an athlete, regardless of the type of activity being performed. Relays can occur in running, swimming, cross-country skiing, skating and, I suggest, in care home nursing. Whilst speed is certainly not the essence of a nursing shift (with staff often overstaying their prescribed shift times, working overtime just to get the job done), there are many ways in which concepts collide in relay racing and in nursing. For the care home nurse feeling anxious about their impending shift, overwhelmed by the responsibility and workload ahead, the idea of being a part of the whole, ‘a part limited in time and space’, can be strangely comforting. The largest relay event in the world is the Norwegian Holmenkollstafetten, which had a total of 44,160 relay-competitors in 2,944 teams on May 10, 2014. According to one estimate, there are more than 36,000 registered care home nurses (or ‘runners’) in England alone, and 11,300 care homes in the UK, each with varying numbers of wards or units (‘teams’).

Carrying the baton

For care home nurses, the workload is plentiful, the workers are often few. Like a baton made of gold, our caseload is heavy but precious too; like relay runners, we carry the baton alone for our stint, with no other nurse or doctor within the ward for the most part. We carry comorbidities, polypharmacy, death, dementia, frailty, falls, complex wound dressings, sudden sepsis, worried relatives, emergency admissions and administrative duties and we feel the weight of the work on our shoulders. Run with it we do, taking care to ‘rest, fuel and rehydrate’ along the way. As we run, we remember the 6 C’s of nursing: care, compassion, competence, communication, courage and commitment, outlined in 2012 by NHS England.

A number of these are core values for runners too, alongside carbohydrates, crosstraining and cooling down.

Sometimes we carry the baton even when we’re not at our best. Rei Iida is remembered as the Japanese teenage relay runner who completed the race with a fractured leg; I’ve known nurses beset by personal disappointment, illness and tragedy who have been able to model true compassion and empathy to those they care for, really walking for a while in the patient’s shoes. Nurses must take care of themselves, however, to sustain their ability to provide care for patients. Compassion fatigue and burnout are very real in this stress-filled profession.

Passing the baton

“When a nurse hands over responsibility of care to another nurse there is an opportunity for error if all the important medical information is not shared thoroughly and efficiently. Failing to mention – or grasp – information may result in delays in treatment or diagnosis for the patient, inappropriate treatment, or failure to provide appropriate care,” writes the Effective Practice and Organisation of Care Group in the Cochrane Library.

An accurate handover of clinical information is essential to ensure continuity of care and patients’ safety, just as a team’s baton-passing efficiency is vital to success in the sprint relay. But are we getting it right? Should handovers be done at the bedside? How much needs to be written down? What role for pre-recorded voice handovers?

One hospital nurse that I knew flatly refused to receive the baton, walking away from a handover because she wanted to look after the more acutely ill patients. In nursing, there are a few situations in which refusal to treat is appropriate: this was definitely not one of them; disciplinary action and dismissal are likely.

In nursing, there are a few situations in which refusal to treat is appropriate.

Dropping the baton

The Medicines and Healthcare Products Regulatory Agency received 78 reports of falls from hoists between 2011 and 2014 which included three deaths and nine incidents resulting in severe injury. If a runner drops the baton in a race, the team is disqualified; fines and even prison sentences can follow fatal falls in care, if equipment, training or competence was found to be lacking.

A myriad of mistakes are however possible during the nursing shift, and for some of these a #learnnotblame culture is important. Often there is no explanation, it’s just a ‘stupid mistake’ caused by inattention and not by ignorance; other times pressures from within or without may be relevant. From the patient’s point of view there is rightly no acceptable rate of error; nurses (and other healthcare professionals) are though subject to human frailty just like anybody else.

A myriad of mistakes are however possible during the nursing shift, and for some of these a #learnnotblame culture is important.

Mixed gender relays

“A male-and-female 4×400 metres will be held on the track at Tokyo 2020, alongside a corresponding 4x100m medley in the pool. A mixed team relay has also been added in triathlon, along with mixed team events in judo and archery and a mixed doubles competition in table tennis, doubling the total number of mixed events at the Games from nine to 18,” writes Ben Rumsby in the Telegraph.

More men than ever are considering a career in nursing, with UCAS reporting a 50% increase in the number of 18 year old men applying to the profession in the last decade. The recent “We Are The NHS” recruitment campaign, led by NHS England, helped to challenge the image of nursing as a female career. There’s still a way to go though since, according to the Nursing and Midwifery Council, men made up just over 10 per cent of the UK’s 690,000 nurses in 2017-18.

Legs and laps

Each relay race consists of a set number of stages, or legs, usually four, each run by a different member of the team. Each twenty four hour period in care home nursing is sectioned into stages, each overseen by a different nurse. Traditionally, the shifts were the early shift, the late shift and the night shift. More common now though are the twelve hour day shift and the twelve hour night shift.

Whilst being cost effective and allowing staff to enjoy more days away from work, these newer shift patterns have also been controversial, with concerns raised over performance, fatigue, stress and patient safety.

The number of laps in a relay varies. With each lap being 400 metres, the two standard relays are the 4×100 metres (one lap) and the 4×400 metres (four laps), but others such as the 4×800 and 4x1600m are possible. In the care home some residents die within days of arrival, whilst others spend a peaceful few years at the end of life. Recognising dying and predicting death are always difficult.

Team spirit

“It hurts to see a true legend, a true champion go out there and struggle like that,” said Bolt’s teammates after he suffered a hamstring injury and was unable to complete. Similar compassion towards colleagues is sometimes absent in nursing, and the Royal College of Nursing has called for employers to safeguard their staff against ridicule and criticism when things go wrong.

Euphoric emotion, laps of honour and even signature victory poses (think ‘Mobot’ or the ‘Lightning Bolt’) are to be expected at the end of a successful running race.

Celebration after the care home relay is less jubilant but more deep-seated and profound. The faithful delivery of compassionate care over many years is a victory; working well together as a team in trying circumstances should give reason for pride. When a resident ‘dies well’, the team can feel a certain happy sadness. I saw this when a 102 year old resident passed away peacefully, days after asking – “can I go now?” Staff lined the corridors as she made her final departure. She had run her race; we had completed the relay. In ancient times the main objective of the relay was to bring a sacred flame to its resting place through torches of fire; in care home nursing, the aim is also to see the journey through.