Reflecting (because every nurse loves a good reflection)

Did you know my blog has lasted longer than my nursing career did??

A failed career in Sports Science- well it was a career that never started thanks to my lungs resulted in me falling into nursing. I never thought I would be a nurse. If you were to ask people what I would end up doing as my career (albeit short) it would not be nursing. It would most likely be something to do with sport.

I can honestly say I have enjoyed every single minute of my nursing career (there may be a few exceptions but generally). From day 1 at uni to what turned out to be my last day (I wish I knew it was at the time).

I have looked back and have some key highlights from over the years.

First Year Student Nurse-

  • The first day of uni and sitting in a lecture theatre with about 250 students and not knowing anyone, wondering if I had done the right thing.
  • Pulling on my student nurse uniform for the first time and feeling so proud
  • My first hospital based placement in the Renal ward and working out that Cat was actually my cousin.
  • Fainting on the ward after a patient split their head open and being fed toast by Sheila the ward clerkess who also kept asking if I was sure I was not pregnant!

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Second Year Student Nurse-

  • Being a student nurse on the high dependency ward, having an asthma attack on the HDU ward and then later that day being a patient on the ward.
  • My ITU placement at the Western General where I got to see brain surgery and also on night shift looking out the window of the break room and seeing my bedroom window. It made for really long night shifts.

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Third and final year student nurse

  • Once again fainting but this time in theatre while wearing a lead dress as it was radiology. It was an 8 hour operation to stent a renal artery and it was very hot so down I went, stumbled out of theatre and fainted again in one of the consultants offices!!
  • Being terrified that I wouldn’t pass my degree as I could not revise properly because my grandpa was seriously unwell and had major heart surgery in the lead up to the first lot then was on palliative care at home and died just before my final ones. Thankfully stuff must have sunk into my brain and I got my degree with distinction.
  • Management placement in renal and always being told I ask a lot of questions, but also always asking people to test me as I was applying for jobs so wanted interview practice. Turns out that practice was not great as had an awful interview but thankfully got the job.
  • The day I got told I had a job on the renal ward I was on nightshift and remember Laura the other student nurse from my year also had an interview but neither of us knew if the other person had got the job so we were super awkward around each other till we both knew!!

Of course the biggest highlight of my time as a student nurse was graduating and getting a distinction in my degree which meant I could go on an register to be a staff nurse with the Nursing Midwifery Council.

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I had 3 years of being a student nurse and then 7 years being a renal nurse where I spent all my time in Renal. Oddly I hated learning about the kidney in school and spectacularly failed my Biology AS Coursework which was about the kidney!! I was not much fussed for the kidney at uni either but once on the ward I found it fascinating. I think its because I am a practical learner!

It has been really hard to pick just a few highlights or memories that have stuck with me from my time as a staff nurse on the renal ward.

  • Pulling on the cornflower blue uniform for the first time and sitting in handover waiting to be given my first patients. I was so scared. I kept thinking what happens if I do something wrong or kill one of them etc. I had millions of scenarios going on in my head all negative of course.

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  • Every nurse will remember their first cardiac arrest. I heard the arrest buzzer go off and I was standing next to the crash cart when it happened, so I grabbed the cart forgetting to unplug it from the wall and off I went. I didnt get far before I jerked back and knew I had forgotten to do something fairly vital!
  • I did a bank shift on the transplant ward. I knew about kidney transplants as had dealt with patients who have had failed transplants etc but never really spoken to someone with a new transplant and one that was working. I was curious. It turns out that patient taught me a huge amount. Firstly they don’t take your old kidneys out if they don’t have to and then when asked to see what their scar was like and helloing them pull their jumper up thinking the scar would be at the back I was shocked when they started unbuttoning their trousers. Transplanted kidneys go in the pelvis!
  • Catching a patient who had really horrific bloods and lots of fluid on board munching on lots of crisps. When advising the patient that perhaps they shouldn’t eat them as they are so high in salt and this will make them super thirsty etc. I was told that it was ok because they were cheese crisps and not salted ones!! I must say I couldn’t help but laugh.
  • In the ward you get given 4 patients a shift on day shift. Either one bay of 4 people or 4 side rooms. I had a bay of 4 people this particular shift. We were also due for an inspection this same shift. I start to get all my patients up and washed, go for my break with one patient left to wash. Come back from my break to find water pouring out from under the bathroom door, one patient not in their bed so I think they must be washing themselves. Next thing I see is the clinical nurse manager coming out the bathroom soaking wet with the patient. She had decided to be helpful and wash my patient before the inspection. I was very grateful to her for doing this by my goodness she made a mess!!
  • There is of course the Christmas parties, tea parties and just general camaraderie of being part of a team.

When my lungs got too much for me to keep working on the ward and when patients were offering up their beds to me as I looked so unwell I was given the chance to move to the Community Dialysis Team. This was a job I loved. I could spend time with patients, work their treatments around their life and felt I could really make an impact to their lives. Of course there are some memories from this role too

  • Being back in my own clothes and everyone calling me Dr- I think because I wore chinos and a shirt or chinos and a polo shirt.
  • My first day being shown the ropes and managing to burst a bag of peritoneal dialysis fluid all over a patients bed (I was mortified).
  • Coming into work but not feeling great, which was then made worse by people smoking at the doors so I ended up in quite a bit of difficulty to the point that my boss found a wheelchair and basically ran with me in it to A&E. So embarrassing and terrifying (not the attack but the wheelchair driving!!!)
  • Seeing patients transform as they start dialysis and really getting to know them, and help them get their treatment optimised so it can still fit in with their lifestyle so they can pursue their hopes and dreams.

Over my entire career there is one moment that stands out above and beyond everything else and that would be when the whole renal team and chaplaincy worked together to pull off a wedding for a patient who was still very young but had to withdraw from dialysis because all her access failed. The wedding was put together in an afternoon and each department did their bit to being their bit of special to the event. It was lovely to see everyone doing what they felt was right from decorating the rooms with the christmas lights, to getting 2 beds into the side room, sneaking in some beer and champagne to celebrate the marriage. It is not only an event that is a moment in my career I won’t forget but in my lifetime I won’t forget.

In this blog post I could go on and on and write about so much because I have really loved my time as a renal nurse. There have been lows but then there are lows with all jobs.

The biggest low for me is that it has come to an end and I couldnt really say goodbye. My last day as a nurse I didnt know it was going to be my last day. Often when people leave their jobs they know they are moving on and retiring so can say goodbyes. I didnt. I have so many people who have been so influential in my career and so many patients that have shaped me as a nurse that I would have loved the chance to thank them and say goodbye.

For now I am no longer working as a renal nurse. I might one day be able to go back and practice again once my health is in better shape but for now my career is on pause and who knows the it will resume again.

For now this is me…..

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Another chapter ending in my life

“the uniform I love is the uniform that saves me and is killing me” has been a statement I have written many times over the years.

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I posted on social media a few weeks ago now to say that I would not be coming back to my job as a community dialysis nurse. I would be ending my career as a nurse come April 2020.

It has not been a decision I have taken lightly. I have spoken to a number of different people including my family, respiratory team and my bosses at work. Last January I was not in a good place physically or mentally. I had come off the back of a really bad run of asthma attacks a rough hospital admission and for the first time ever I did not feel able to go back to work. Fast forward a year and rather my health being better I am in a worse situation, my health is at an all time low and it is hard to cope with my daily life and everyday tasks. I am relying on my mum more and more so there is no way I could continue working.

I am beyond devastated at having to give up nursing. I fell into nursing after having to give up a career in sport. I was determined that I would do all I could to get myself through university and qualify as a nurse. It was hard but I did it with the support of my tutors and of course my consultant. Soon after qualifying I got my dream job working in the renal unit which is where I stayed. I was so fortunate to have really understanding bosses who were so accommodating and made changes to help me and enable me to continue doing the job I love. I pushed on so much and often worked when potentially I should not have but it is because I genuinely loved my job. I loved the patient interaction, trying to help patients manage their condition and get the most out of their life.

Closing this chapter does not mean it is the end of nursing forever. Nursing is a career I will always be able to come back to when my health is better. For now it is just on pause.

A lot of people have been asking what I am going to do and will I manage ok without having an income. These are things that I will talk about in another post. Im am so gutted but it is for the best. My patients, colleagues and family were worrying about me when I was working and if I was ok. They were seeing that I was having no quality of life and I was living to work and that was it.

Nursing may have been put on hold just now but I am not going to give up on my dreams.

 

Corona Virus what does it mean for severe asthma?

Corona virus, COVID-19 or as I like to refer to it as “the virus” is the hot topic just now and rightly so especially as the World Health Organisation has just declared it to be a pandemic.

I have not posted anything on facebook, instagram, twitter or my blog about the virus because everywhere is saturated and there is a lot of different information about what to do and what is best. The only thing that is consistent is that hand washing is essential and that for the hand washing to be effective it must be 20 seconds minimum. There has been some fantastic stuff developed around songs that you can sing while washing your hands. This is a favourite: Bohemian Rhapsody (it is only half a routine so DO NOT use this to wash your hands)

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What does the virus mean for someone like me?

It is a very serious situation. The effect for me could be devastating. A basic chest infection is horrific and puts me in intensive care and that is a condition that has a treatment. This is a new virus that has no vaccine and no treatment. Should you get the virus the medics can support you and support the area of your body that is failing but otherwise you just have to fight it yourself. When you already fight each day to try and stay well this is an added extra that your body really does not need.

There are mixed messages going about for people with respiratory conditions. The issue with asthma is that it is so varied. For someone with mild controlled asthma the virus might not be that big an issue but I am immunocompromised due to long term oral steroids at fairly high doses and I pick up everything.

To be honest I am terrified. The last hospital admission was really hard and the recovery has been super hard. I have had to invest so much time and energy to get myself back on my feet and the thought of potentially having to do this again put the fear in me let alone to do that recovery plus having COVID-19 on top of it.

What steps am I taking to try and keep myself well?

I am just trying to be sensible but have taken a range of measures to try and protect myself apart from hand washing etc.

  • Withdrawn from speaking events including EyeforPharma in Barcelona, Asthma UK Centre for Applied Research Annual Scientific Meeting and various others. Both of which I am gutted about as was really looking forward to them.
  • Withdrawn from giving a lecture to nursing students at Edin Uni on Professionalism
  • Stopping coaching lacrosse in school
  • Have not been accepting invitation to attend events that are hospital based and any events that has been scheduled I have asked to call in remotely if possible especially if there is a large number of people attending
  • I have done all my shopping and meal prep so I don’t need to go to any supermarkets. i won’t have fresh fruit and veg but I have frozen fruit and veg so won’t miss out totally.
  • Finally the biggest one for me is that I am taking myself out of the city for a few weeks or for as long as needed. I am heading up north to my parents place which is in a small village away from any cities and in the countryside. This will minimise my contact with people and hopefully minimise my risk of catching the virus. I am concerned about getting ill when up north but it is safer to be away than staying in the city.

Its tough to know what to do for the best. With advice changing on a daily if not hourly basis everyone is in a state of flux constantly. We seem to have gone from panic buying toilet roll to panic buying everything that you would keep in a store cupboard.

One other thing I have been very conscious of and I have not mentioned is being in touch with your care team. I am taking the advice primarily from my respiratory consultant but then also my asthma nurse and GP as well. I need to consider what they suggest and listen to what they say over the next coming months more so than ever.

For anyone else who is in a situation with their health like I am I know it is a really difficult time. I am fortunate that I don’t have work to juggle as well as that would just be a whole new ball game. I think if I did still have a job I would be speaking to my managers and explaining my situation. On the whole from others who I have spoken to who have health conditions and work their bosses have been pretty accommodating and supportive. Oddly the thing I have been hearing most is that they wish their bosses or workmates would stop going on about how they have to be careful and or how they need to be aware of the news etc because of their situations and being immunocompromised etc. Many know they are just doing it because they care but even Ia have been getting irritated with people telling me to watch out and I don’t work just now and don’t see a huge number of people right now!!

For now we just need to keep up to date with the NHS advice and hope that things do not escalate.

I will continue to prepare for the worst and hope for the best as much as you can with an unknown situation.

You can disagree with your Dr, its called self advocating.

Yes Dr, I will take that as you prescribe despite the horrible side effects stopping me living my life.

How often have you found yourself doing this? Do you know that you can speak up and disagree with your Dr or healthcare provider.

In the UK when it comes to healthcare traditionally we are not very good at speaking up for ourselves. We often go with what the Dr or Nurse says because they have done the training and what they know is best. This is a very antiquated view now I think yet we still want to please our Dr’s so will do what they say and take what the prescribe. We often think if we don’t do this we are seen as a difficult patient and no one wants to be a difficult patient do they!

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Speaking up for yourself can be daunting, I remember thinking I can’t question a Dr, they went to medical school for 6 years and have done countless more years honing their skills in whatever speciality they chose so who am I to question them. I only live with the condition I don’t (or didnt) know the physiology behind my diseases or the best treatments for them. This is what the Dr’s know.

I wish 14 years ago I knew what I know now. I have written about this before but 14 years ago my Drs had me on prednisilone (which frustratingly I am still on) and kept weaning it down as they did not want me on it long term. I didnt understand the long term side effects of prednisilone at the time but was getting fed up of feeling good while on higher doses of pred but then start feeling awful as the dose reduced and came off it. It was like a constant rollercoaster. My answer to this was just not to take the pred. I didnt feel good not taking it but at least I was not feeling great to then have that feeling taken away and I would go back to my life being put on hold. I found that I preferred to know where I was with my lungs and adapt to life where my lungs were not that great. This did not work out well for me on several fronts:

  • My health was awful, I couldn’t do anything, I was missing out on life, friends, sport, uni.
  • My mental health was at an all time low because I couldn’t do anything with my friends and just be a normal student, but I could not cope with being able to do things with my friends while on a high dose of pred for it to then be taken away again.
  • I was lying to my medical team, how could they trust me if I was not doing what they wanted me to do.

It all changed when I managed to get a chest infection and put off going to the Dr. I ended up in intensive care really poorly. I was questioned by my consultant about why I waited a long time to get seen and go to hospital and why did I not put up my prednisilone according to my care plan when my peak flow dropped.

It was then that I opened up to the Dr and said what I had been doing and why. I explained that I didnt like knowing that while on a high dose I would feel well and be able to do stuff and then the dose would be reduced and I would not be able to things because of my chest so would prefer to just not know what it was like as it was a false sense of reality that was just then taken away.

Once I recovered from that hospital admission I had a meeting with my consultant and asthma nurse to have a frank discussion about my asthma, asthma care, medication regime and care plan. This was the first time I felt that it was ok to speak up and say to them what was important to me in life and what I wanted to be able to do etc. It was great as we were able to work out a lot of things and while I had to make compromises as it is not possible to do everything I wanted to be able to do but now my consultant really understood me as a person and our working relationship grew because I was able to be honest. I was also able to bring suggestions to him about new medications I had heard about. It became a 2 way conversation which I have now always made sure I have with all my Drs and nurses involved in my care.

It can be daunting at first to advocate for yourself but I can assure you it is the best thing you can do. Drs know conditions and medications but they don’t know you and your life unless you speak to them about it. We didnt choose to develop chronic health conditions but we do choose the life we want to lead and this includes how we manage our health, what medications we are prepared to tolerate and what we are not. Some side effects may be ok for some to put up with but not others depending on life situations. For me just now I don’t mind my dose of prednisilone changing quite a lot because I am not working (I find that when the dose changes my insomnia is so much worse) but if I was working then I would speak to my Dr about not having the dose fluctuate so often so I could try and manage my insomnia better.

Self advocating is not about arguing to get your own way but it is allowing your medical team to work with you to get the best management plan for your condition and your life. If you as a patient are involved in the decisions about your care and agree with them then it is highly likely you will be a more compliant patient with medication compared to a patient being told what to do and what to take when who is less likely to comply because it is not what they want to do or it does not fit in with their life. No one likes being told what to do but if we are involved we are more likely to follow instruction.

It is important to remember that while self advocating is good, not everyone feels comfortable doing it and would prefer to just do as the medical professionals say. That is fine too.

I am so glad that I was able to learn that my voice as a patient is just as important. I do have knowledge, I am an expert patient in my own health and my conditions. I am allowed to bring my thoughts to the table when Im in appointments as I need to try and get the best management for my health possible.

I will leave it here but I would say self advocating does not make you a difficult patient, it makes you a patient that cares about their health. This is why I self advocate and why I am also a wider health advocate and will advocate for various health conditions like severe asthma and allergies.

Is severe asthma different to asthma?

In my last blog post I mentioned how I met some other people with severe asthma at a BLF-AUK event where we had a conversation about asthma and severe asthma.

It may have the same mechanisms in that it is a condition where the airways become inflamed and irritated causing difficulty breathing but here ends the similarities. The way it displays itself is different. The way it is managed is different. The way it impacts your life is different. There are too many differences to name them all so this is why we came to the conclusion that it needs a different name.

When someone hears  severe asthma they think its that common everyday condition that every second person has. The part they have not heard is the “severe” that went in front of the asthma which makes it very different, but because asthma is so common people are very relaxed so don’t take it too seriously or act urgently when dealing with it. This leads us to become so frustrated. I can think of so many times where I could potentially have not needed to go to ICU if the Dr I saw at the front door when arriving in A&E took my severe asthma for what it is and not treat it just like asthma.

One of the challenges that people with the condition severe asthma face is that so many in the medical profession refer to those with asthma that is not in control as having severe asthma or brittle asthma when they actually don’t. There are so many terms floating around to describe asthma that is not controlled for example

  • brittle asthma
  • severe asthma
  • difficult severe asthma
  • difficult asthma
  • severe brittle asthma

That is just a few. The issue arises is that some of these terms are used incorrectly and we have GP’s or nurses in the GP surgery telling someone with asthma that is not in control that they have brittle asthma when they don’t. They just don’t have their asthma in control at that moment and need some medication tweaks.

The types of asthma such as brittle asthma can only be diagnosed by a specialist asthma consultant at a specialist hospital. Not even asthma consultant at local hospitals can diagnose it as there is a raft of specialist testing and multi disciplinary input to ensure that everything is ruled out before you are diagnosed with this very rare type of asthma like severe asthma or type 1 or type 2 brittle asthma.

This is why I and others have been thinking that perhaps these extremely rare forms of asthma need a different name that perhaps does not even have the term asthma in its name to save us as patients from not being treated correctly. Maybe just then we won’t suffer so much when in hospital.

Another big issue for some with severe asthma is that we can look ok one minute and the next we are fighting for our life or we look ok but actually we are working incredibly hard to breathe but don’t want people to know. You cant see severe asthma unless you are having an attack which makes it so hard for people to understand just how debilitating it can be. How every aspect of your life is dictated by your condition, that even taking every medication that is there for asthma it is still not enough to give you a quality of life. It is hard to think that despite taking 30 different medications each day I still don’t have control of my health or my breathing to where I would like it.

I wish my lung condition could be covered by the term asthma but severe asthma is far more complex to manage, treat, control, and understand. No 2 people with severe asthma are the same which makes the condition so much more complex to diagnose and manage. This often leads to very frustrated patients and frustrated healthcare practitioners because despite everyones best efforts life is not good, hospital admissions are just part of life, even ICU becomes part of life which should never be the case.

This is why I think severe asthma needs to be totally separated from asthma and doing this could be achieved by changing its name to stop people from being complacent when treating you in an emergency situation.

I hate living with severe asthma and hate that it is so poorly understood. Maybe one day there will be a huge break through and suddenly all of us whose life is dictated by their severe asthma is no longer like that. Until then I will continue to try and raise awareness of what it is like and just how serious a condition it is.

BLF-AUK Respiratory Action Plan Meeting

I was recently at the first event since the partnership of  Asthma UK and the British Lung Foundation. It was fantastic to see BLF colleagues with the Asthma UK logo on their name badges alongside the BLF logo. Also being welcomed with open arms too was lovely. I was a bit daunted to attend this event as I didnt know anyone however as soon as I walked into the room I spotted a familiar face Dave from Chest Heart and Stroke Scotland who had attended a PPI event I was teaching at. As more people arrived I then saw Toni (a fellow patient) who I got to attend the Garden Party with which was good too but actually by the end of day I was able to speak easily to so many people and have come away part of a whats app group.

The table I was on turned out to be one full of severe asthmatics (not done on purpose all by chance). As we got talking it was amazing speaking to others who have had the exact same experiences as I have and the way you feel as well. I think the biggest thing for me was that you would not be able to tell that any of us were seriously unwell and that 2 of us have had far too many intensive care stays to count.

One thing that did come up several times in conversation was around the term severe asthma and what it means. We all came to the conclusion that severe asthma is almost a totally different condition than asthma is but this is for another blog post.

The main point of the meeting was to discuss certain points of the Respiratory Care Action Plan which has been drafted by the Scottish Government however they have one huge fundamental flaw. They did NOT consult with those who have or are affected by respiratory conditions, so the BLF-AUK held a meeting to discuss key points which need patient in put on. In the room there was a mix of people with different respiratory conditions.

One part of the meeting that I found frustrating was that it became a bit of a platform for people to spout their complaints about their GP and how they never get to see their GP or if they want to see their GP they have to wait. This is just the way it is now but moaning at events like this is not going to get anything changed. The GP system is not ideal but there are so many who are not using the GP correctly like with A&E so that others miss out and suffer as a result but a consultation on a action plan is not the time to complain.

Asthma I think and I may be wrong is unique amount respiratory conditions because unlike other conditions which mainly affect the older generation asthma can affect anyone young or old. In the room everyone was much older than those with asthma. The other thing that made it unique is that unlike COPD asthma is not really a progressive disease. It goes through phases of being controlled and uncontrolled but generally won’t continue to get worse as you get older limiting your ability to function. So the needs of those with asthma are very different to those with a constrictive airways disease compared to a revisable airways disease. I think those with asthma in the room were able to speak up and give a good balanced argument for our opinions and why us as asthmatics think as we do.

I did get very frustrated when asking a few questions to be interrupted by those with COPD who clearly has no understanding of any other condition outside their own so would butt in with their opinion and how I was wrong. The one that got me really riled up was discussing spirometry. I asked what they meant by spirometry to the facilitator as it was a broad term and encompasses a number of different tests. The context of this question was on the background of spirometry being used in primary care. This person jumped in and would not let me explain what I meant  and told me that spirometry is blowing into the machine when you sit in the glass box. I was wanting to know if they meant basic lung function by doing speak flow, or FEV1 or more advanced lung function tests given that the context is primary care. I was just really annoyed that some people were not given the chance to ask their questions or finish asking their questions without people butting in. The whole purpose of consultations and being involved patients and the public is to listen to each other and accept each others views wether you agree with them or not particularly when it comes to a variety of different conditions especially when we are all experts of our OWN condition but not in other peoples conditions.

The whole day was really good and I really hope the BLF-AUK got a lot of helpful information to take back to the government about their action plan and hopefully make some changes now that patients have been consulted. I look forward to seeing the result and to see the finished Respiratory Action Plan. If anyone is interested in giving their own feedback on the action plan they can do that here .

 

 

Being a Health Advocate

and how does it differ around the world??

Last April I was in Dallas Texas attending the HealthEvoices (HeV) meeting. A meeting for health advocates to meet and learn from each other. I went out there thinking I knew what health advocacy was but I was wrong to some extent.

A while back I put the question out on social media “What does health advocacy mean to you?” and I got some very interesting answers. What I found most intriguing was that there was a clear split between thoughts in the UK and then thoughts over in the US and Canada.

Pre HeV my understanding of health advocacy was essentially speaking up for yourself or family member to ensure you can get the best treatment, or best healthcare you can for your condition to ensure you can live as independently as possible and without too much interference from your health condition.

I also thought advocating for myself meant me speaking up to my healthcare providers wether it be my asthma consultant, asthma nurse, GP or whoever and tell them the parts of my treatment I did like, the parts I didnt like and also the things that were important to me in my life. I have spoken before about a period in my life when I didnt like the treatments I was on because of the side effects and the amount it intruded in my life so instead of speaking up and saying this I just stopped taking the medication and didnt say anything until I got really unwell. I thought I was wrong to tell my team that I didnt like the treatment they wanted me to be on because they were the drs after all!! It took for me to get really unwell to be able to tell the Drs why I ended up so unwell. They obviously asked me why I didnt tell them rather than just not taking the treatment, but I thought I didnt know as much and had to do as they said. From this point on I learnt that I could speak up for myself and say to the healthcare team that this was my views and opinions etc.

This is on the whole what those in the UK replied with when I asked about health advocacy.

In contrast others mainly (with some exceptions) from the US and Canada said that health advocacy was the sharing of ones own experiences and knowledge to help others and raise awareness for that condition. I think in the UK we would see this as raising health awareness.

Since attending HeV I have wanted to bring this contrasting view of advocacy to the UK and really advocate more for those with chronic health conditions and how you as someone with a chronic health condition can get the best information, and be able to live your life alongside your health condition and not put your life on hold because of it.