Nursing in the Orkney Isles20th March 2013
A Loganair plane landing at the island base in Orkney, taking the TVN from NHS Grampian to assess a wound and provide on site training to the nursing staff.
It was always going to present a challenge. How do you provide first-rate health care to a population that is spread over 17 inhabited islands of varying accessibility 16km from the north-eastern tip of mainland Scotland? Twenty thousand people live in Orkney. About 15,000 live on Orkney mainland, the largest island, but on some of the smaller islands the population is in single figures. Tourists also increase the capacity, particularly in the summer months.
Wound Care People spoke to Judy Sinclair (Lead Nurse, Orkney Health and Care and Practice Educator, NHS Orkney) about the challenges facing a nurse in providing complex wound care to the people in Orkney. Judy is based in Kirkwall, the largest town, and has worked for nearly 20 years within the community and, more recently, as a practice educator within the Balfour Hospital. Currently, in her Lead Nurse role, she covers all the islands.
Ten of the islands have one nurse on duty around the clock, seven days a week. There are approximately 35 working in the community in Orkney overall, but within the smaller islands there is a mix of advanced nurse practitioners working on islands without a GP and also community nurses working alongside their GP colleagues — all of whom provide 24/7 scheduled, unscheduled and emergency care. On the Mainland of Orkney there are two teams, each led by a district nurse, with one nurse per team providing an on-call overnight service.
The nurses are mostly resident on the islands, but there are relief nursing staff that provide cover for annual leave, study leave and absences as required.
The four larger islands, Westray, Sanday, Stronsay and Hoy have a resident GP and a community/practice nurse. The nurses work with the GP to provide community nursing, practice/treatment room nursing and emergency care as required. The nursing staff and GPs both live and work on these islands.
Working on an island means that nurses have to deal with every type of case that arises, making for a very mixed caseload. With the size of the population, treatment needs vary and wounds present sporadically. It may be that one patient needs treatment for a complex wound and then another complex or specific type of wound is not seen for another year. This means that the nurses need to have generalised skills and knowledge to deal with all possible types of wound, as the intermittent presentation of wounds can make specialisation and the maintenance of wound-related skills a challenge.
Overall, the islands have an aging population, as Orkney has a high life expectancy compared with the Scottish average, resulting in the usual range of comorbidities common to this patient group. Pressure ulcers, leg ulcers, and trauma wounds are prevalent, as in other areas, and these are managed by the practitioner. An advantage of this is that the patient has continuity and the wound is assessed consistently, with the down side being that it is difficult to get a second opinion or discuss alternative treatment plans. The use of technology is vital for the isles, and digital imagery and computers make this so much easier now.
Ongoing treatment of chronic complex wounds can present the greatest problem. However, recently, managing these wounds has become easier with the introduction of an e-clinic and telehealth service, which links the islands to the Specialist Tissue Viability Department at NHS Grampian. This link has also made it possible to keep more patients with complex wounds at home, rather than sending them to the Scottish mainland for specialist treatment at Aberdeen Royal Infirmary.
The link with NHS Grampian is web-based enabling wound photographs and details of the patient and their wound to be uploaded to a computer. One of the specialist nurses in NHS Grampian will review within 24 hours and provide advice for the clinician along with suggestions of a plan of care. Although it has been more challenging to set this service up within the island practices, it is available within the local Balfour Hospital and Kirkwall Health Centre sites, where it has largely transformed the delivery of wound care. In these centres, the availability of telehealth links provides the nurses with specialist input and advice, an assurance that evidenced-based care is being delivered.
These links were forged initially because one of NHS Grampian’s nurses is an Orcadian and she was kind enough to provide some education and advice while on her holidays! However, since 2010, this has become a formal link and NHS Orkney work closely with all the NHS Grampian team, who provide training and advice about a range of tissue viability issues.
Recent cases that have been successful on the outer islands have included a man who needed compression bandaging but was resistant due to a previous bad experience. With the intervention of the NHS Grampian team, he was finally convinced to try it. With some training for the nurses on the island (two of whom were new to community nursing) and ongoing support from NHS Grampian, via email and phone, the ulcer healed in six months and remains so, with the patient concording with daily compression therapy.
There was also another frail elderly patient who had chronic extensive leg ulcers, who had previously been recommended for an amputation but had refused. His living conditions added to challenges and made management difficult. He slept in a cold bedroom and during the day would sit by a hot fire. He also took an active role in his treatment and care and needed to be assured by the evidence of what was being used and why. He really enjoyed the fact that we had a link to ‘specialists’ in Aberdeen and this helped him both to agree to the treatment plans prescribed and supported the nursing staff to learn and develop their skills.
As a result of the remote nature of the work, the team have established a good support network. This is vital when working in isolation. It can be tricky being a lone practitioner when even the smallest things that would be taken for granted in a larger setting become difficult, such as getting the correct dressings and equipment out to the island when the planes have been grounded due to fog, or the boat does not go due to bad weather. It is important to plan in advance for stock and it can take time to identify what you need and get it in a timely manner. There is limited availability from occupational therapy, physiotherapy and other members of the multidisciplinary team, but NHS Orkney continue to explore the use of technology to improve care and reduce travel time for patients, with the telehealth links with NHS Grampian being an important part of improving the quality of care delivered to the benefits of both patients and staff alike.
Rhona Muir, a district nurse/family health nurse, working in NHS Orkney said: ‘When I first started in the community in Orkney many years ago, decisions regarding wound care and treatment often depended on the individual practitioner’s knowledge and experience. Now, patients cared for at home often have multiple comorbidities and therefore any subsequent wounds can add further challenges to care provision. Given these complexities, having links to the TVN through the e-clinic is vital in supporting the generalist role in providing evidence-based care.’