Reducing the workload

Wisley, August 2011

My workload reached the point last week where one of my colleagues (who only has an outpatient clinic every two weeks) offered to help out, and I accepted gratefully, handing over six patients who really needed reviewing. That relieved the immediate pressure, but we had another discussion and agreed that I would hand over my three outlying wards to the other two Band 5 Dietitians. Since then, I have felt so much better that I actually told someone that I'm enjoying my job now.

I have felt slightly guilty about this transfer of work - maybe I'm just not doing as well as the others, maybe I'm too slow? But then I think - there's a new Dietitian starting in May who's only going to be looking after one of my wards as a full time job. While she will be able to address aspects of care that I don't have time for (e.g. why aren't patients routinely weighed once as week as protocols dictate?) I have four other wards to look after. Or I did have, and my colleagues insist that they are able to manage with the extra workload, which actually only came to two or three patients each. My main wards each have between about ten and twenty patients on my caseload, on average.

Then there was the Nutrition Nurse, who asked me why I hadn't applied for the more senior job when it came up. Nutrition Nurses are part of a team that make the strategic decisions about nutrition - whether a feeding tube should be surgically inserted, for example, or whether IV feeding is appropriate - and also do some hands-on nursing relating to the tubes. They are in charge of making sure there is no infection at the tube site, and no other complications with the tube components, and will pass nasogastric tubes if the nurses can't manage it, and help to unblock tubes in appropriate ways, and are responsible for a specific type of tube called a nasal bridle. I also discovered recently that they also assist with the endoscopic and surgical  insertion of gastrostomy tubes (feeding tubes into the stomach).

The main problem with nasogastric tubes is that they are designed to be temporary - easy to insert, but also easy to remove. Patients routinely cough them out, or pull them out, because who wants a tube going up your nose and down your throat, especially if you can't understand where you are or why you are there? I expect that some patients have specific and ethical objections to being fed, but often we can't ascertain whether this is case, if communication has been seriously disrupted by a stroke. So decisions are made by the Nutrition Team according to their assessment of the patient's best interests. If a patient repeatedly pulls out an NG tube, one of the options is the nasal bridle.

This is an NG tube that is not just passed up the nose and down the throat and fixed in place with tape, but a 'bridle' is also inserted behind the nasal septum. This just means that the tube can't be pulled out easily, and pulling on the tube may become painful, preventing all but the most determined patients from removing it.

Getting back to my Nutrition Nurse, I told her that I wouldn't have been given the more senior job because I've only been working as a Dietitian for two months. She was gratifyingly amazed, which made me feel great: someone who doesn't know anything about me other than my interaction with the patients thinks I'm doing a good job. My Dietitian supervisors and managers don't actually see as much of my day to day work as the Nutrition Nurses. So that was a very good day at work.

When the new Dietitian starts in May I will hand over the largest chunk of my work, and responsibility for all the other wards will be re-allocated between us three junior Dietitians. So the workload will be even more manageable, and I may have a little bit more time for thinking and planning, which hardly happens at all at the moment. I'm looking forward to it, and actually enjoying my job in the meantime, now that the workload is more manageable.