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Walking by is not what I want to do but walking by is what I do on a regular basis. I am ashamed to write this, to think this, to do this. I don’t think I am alone as I have seen others do it too. We are not bad people, but I can’t help but think that we have turned into bad nurses. The last thing I wanted to be was a bad nurse. This was never the plan… it’s crept in, without me knowing it was happening. Until now. How has this happened? How have I become the nurse I despise? I work on an acute medical admissions unit. We have patients that are admitted from the emergency department (ED). They are unwell, often too unwell to come to us, but patients need to be moved. “Keep ED flowing” – its all about flow. I have begun to hate that word. We have 36 beds in total. We have a nurse/patient ratio of 1:6. Sometimes 1:8 if we are short staffed. Throughout the day we can have up to 12 patients that have passed through those six beds. They go to other medical wards, respiratory wards… anywhere that has space. If we have no room the ED gets backed up and ‘flow’ stops. I have pressure from my nurse in charge to move my patient to another ward, they have pressure from the bed manager, who has pressure from the ops manager. I have sat in on bed meetings, it’s not easy listening. A high up manager barking “we need 45 discharges by mid-day”; it’s not achievable… it goes on every day. I’m getting these patients ready for transfer. Safety booklets, pages long to be completed: nutritional score, waterlow score, bowel chart, touch the toes chart, fluid chart, turns chart, fall proforma, NEWS charting, food chart, clinical pathways, next of kin contact details, let alone my documentation for those few hours they have sat in that bed. All the while, drugs need to be given, intravenous drugs, not just for my patient but I have to help the agency nurse in the next bay as “she can’t do IVs”. Patients need washing, turning, feeding, monitoring, bloods to be taken, wounds to be dressed, hourly pump checks, blood sugar testing, cannulation and conversations with sick patients’ relatives. These are tasks that need to be done on time. If not – trust policy is breached. Some, I just ‘tick’, especially if it’s a checklist. I know I’m not the only one that does this – it’s normal. So, when I’m in the middle of trying to complete these ever-growing tasks, I hear “nurse can you…” “nurse will you just…” “I know you're busy but...” What do I do? I walk on by. I walk at high speed. I have stopped before. It often stops me completing my tasks. I forget what I was meant to be doing. I have missed a crucial blood sugar check for my DKA patient in the past. Patients do not get their medication on time, patients are not transferred on time (it’s all about the flow), safety booklets not completed, handovers rushed and information missed, documentation scant. I’m always in a rush. I know many of the calls are for toileting. This can take a while. I daren’t look at the pressure areas – my heart sinks if there is one… more documentation, more time away from the other tasks. Patients who come in are often at risk of falling, so need two people to help. I know the next-door nurse is just as busy; I feel bad to ask her/him. The healthcare assistant is often too busy to help, getting patients ready for transfer, doing the observations… relentless. Walk on by. Yes, I do. I am not the only one. What are the Trust priorities? Safe care or flow? The Trust will always say safe care. So why set up the environment that causes unsafe care? Mixed messages. I became a nurse to give evidence-based, holistic, safe care. I go home demoralised. I don’t recognise this profession anymore.

Key points: An evaluation of hospital use among 526 residents aged 65 or over living in 15 vanguard nursing or residential care homes in Wakefield between February 2016 and March 2017, compared with a local matched control group. The enhanced support they received had three main strands: voluntary sector engagement, a multidisciplinary team and enhanced primary care support. Estimations show that vanguard residents experienced 27% fewer potentially avoidable admissions than the matched control group – the effect was stronger among those who had been resident in a care home for three months or longer. But there was no conclusive evidence that overall emergency admissions or A&E attendances differed between the vanguard residents and those in the matched control group.

NHS England and NHS Improvement have worked with a number of partners to identify five key principles which can help ensure that patients are discharged in a safe, appropriate and timely way. The five principles relate to different stages of a patient’s stay: some to the moment of admission, some to their time on a ward and some to the end of their stay. Plan for discharge from the start Involve patients and their families in discharge decisions Establish systems and processes for frail people Embed multidisciplinary team reviews Encourage a supported ‘Home First’ approach The 'Where Best Next?' website lists specific actions for each principle and provides links to useful resources.