"Hit me with your birch stick"!!

Another fascinating day at Tays and TAMK. This morning I was back at TAMK for my presentation and to hear some other people's too. Chris sent me a couple of photos yesterday:

Sorry Helen - if you thought the other one was scary!

Well, I started this yesterday but ran out of time so it is now Wednesday! My presentation seemed to go OK. Chris, the lecturer from Chester, did a really interactive whizzy presentation before me so mine was rather traditional. However, I think that is what most of the audience were expecting. It was quite a challenge to address our healthcare system generally, the recent changes, the health of the population in Nottingham and then discuss case management and community matrons and level 2 case managers in 45 minutes! Again Chris took a photo of me in action:

Can't work out how to turn it round - but you get the picture?!

I heard presentations about treating traumatised children in Finland. They have a specialist unit on their psychiatric unit for children who have experienced  severe trauma (such as abuse, neglect, war, complex loss, attempted suicide). Often these children are mis-diagnosed and severe trauma is quite a new concept. There is now a theory that due to these traumas the brain is actually affected and needs treatment.  It is underpinned by many different theories particularly dissociation, attachment theory and child development is an important aspect. One treatment that is used for children, especially those who are in "therapeutic holding" - I think this meant those who have to be restrained for often long parts of the day, is "Nest Care". This is basically 20-30 minutes of cuddling for the child.

Chris did her presentation about childhood "accidents" - basically saying there were no accidents as they cold all be preventable and set the scene for mine introducing the concept of "upstream" work. This means trying to work proactively to prevent problems rather than reacting when the problem has occurred. After my presentation I heard about palliative care in Lithuania. It was really interesting to hear that the government will not let them adopt the term "hospice" because this is not a Lithuanian word! Palliative care and medicine is a very new concept. It only came into being in 2007 and there are still no courses in palliative care for medical students. There is still a significant stigma attached to sending someone to the hospital's palliative care beds as there is an expectation that the extended family should look after the person.

My meeting with the Chief Executive was cancelled again after I had rushed over from TAMK to meet him. However, it meant I got an unscheduled lunch break and time to let my mind settle and catch up with the BBC news! 

After lunch I met with Esa from security. It was very interesting that their staff / patient security is based in with their fire and maintenance department. They have quite a robust system of reporting actual incidents and "near misses" - this was not a term he was familiar with and he seemed quite taken with this! It seems that these are not done in Acuta (our A&E) or the psychiatric unit - which seemed precisely the places that would have the most incidents and so the most concerns to address! The additional problem is that the hospital is open from 6am - 10pm and there is open access, even on their maternity unit.

I then visited the Pirkanmaa Hospice. It is set in the corner of the hospital site against the backdrop of the forest - a very beautiful situation.

The sign says "Flea Market" - their Hospice shop!

A very lovely and tranquil setting

There are four hospices in Finland (Helsinki, Turku, Hameenlinna and Tampere). In 1999 the first professorship of palliative medicine was established in the University of Tampere.  The hospice at Tampere was built in 2002 and was the first Finnish and indeed Nordic (these are the countries of Finland, Sweden, Norway, Denmark and Iceland) hospice. They have 24 beds and are funded by taxes from the municipalities. There is also a charge which is income assessed. Patients can pay up to 32.5 euros a day but the cost per bed is 230 euros a day to the municipalities. I was really fortunate to meet the founder of the hospice movement in Finland, Eila Haihala as she was visiting with her husband:

A truly remarkable lady

I was given a tour of the hospice by one of the volunteers. There are 100 volunteers of whom only about a third have been involved previously due to the death of a loved one. Volunteering it would seem, is a relatively new concept in Finland. Often it is seen as a threat - that the volunteers will take away the work of the paid workers! However, Tiina, the Chief Executive (right of picture above), of the hospice has a very clear concept of what is nursing and what is volunteer work. Put very simply she said  if the bed is empty the volunteers can change it, it the bed is occupied it is nursing. Marja, who showed me round and Tiina also explained that the Finnish culture is very independent and they have learnt not ask if people want help but rather to ask what help they would like. 

The south facing patient sitting room

A reading tree - art work on loan

The view onto the forest behind the hospice

There are 20 nurses of whom 16 are registered nurses and 4 are unqualified. There are 2 doctors who mainly cover 5 days a week. Tiina explained that because there is not 24 hour medical cover the nurses have to be very skilled in palliative care and particularly around pain management. Although they can not actively prescribe many of the medications are written up on a PRN - as required basis, allowing them some flexibility and freedom to treat.

There is a full time chaplain - a female priest who works very ecumenically, although, there are few people from non-Christian faiths. However, they do have a curtain that pulls across the cross in the chapel area so that it can be used by Jewish and Muslim people.

The Chapel - a small, compact room

Traditionally Pirkanmaa Hospice has dealt with patients with cancer but now they are opening up their beds to those with long term conditions. They have a relatively high number of patients with COPD and so are starting to treat these patients too. They have a physiotherapist who works closely with these patients. It is only a few patients who come to the Hospice either as in-patients or as day care. They have day care each week on a Tuesday. The doctor and nurse who run this offer support and treatment management and there is also the chance of a sauna. It was in the sauna room that Marja explained about the birch twigs. I had thought they burnt them for the heat but it seems they hit each other with them to release the oils!!!

The patients who choose to come as day patients are supported to die at home if this is their wish. They can contact the centre and a member of staff will be assigned to visit at the end of their shift. It would seem that because nurses are relatively poorly paid many work extra shifts and so are more than willing to do this. I had not realised there are also beds in the health centres and so I am sure I shall find out more about this in my final week when I am going to visit one of the health centres.

They are developing palliative care courses including training for the unqualified staff. They are in the process of adopting the Liverpool Care Pathway and were very interested to hear more about this. I was disappointed I could not tell them more but promised to put them in contact with our End of Life Team and for their Chaplain to contact Andrew, my husband, if they wanted more information.

I had a very interesting discussion  with Tiina about the role of nurses and doctors and it would seem that there is still quite a strong hierarchy. The hospice is quite unusual for allowing nurses to take an acknowledged lead. There is also a strong tradition of doctors as managers which is starting to change as there are now more female doctors and they want to practice clinically rather than manage.

The resident cat!

Although there is still a stigma attached to the hospice, it is seen as a place of no hope for some. Most who come there realise the support and care that it can offer. 

Another view of the forest behind the hospice